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Rugg C, Schmid S, Zipperle J, Kreutziger J. Stress hyperglycaemia following trauma - a survival benefit or an outcome detriment? Curr Opin Anaesthesiol 2024; 37:131-138. [PMID: 38390910 DOI: 10.1097/aco.0000000000001350] [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: 02/24/2024]
Abstract
PURPOSE OF REVIEW Stress hyperglycaemia occur often in critically injured patients. To gain new consideration about it, this review compile current as well as known immunological and biochemical findings about causes and emergence. RECENT FINDINGS Glucose is the preferred energy substrate for fending immune cells, reparative tissue and the cardiovascular system following trauma. To fulfil these energy needs, the liver is metabolically reprogrammed to rebuild glucose from lactate and glucogenic amino acids (hepatic insulin resistance) at the expenses of muscles mass and - to a less extent - fat tissue (proteolysis, lipolysis, peripheral insulin resistance). This inevitably leads to stress hyperglycaemia, which is evolutionary preserved and seems to be an essential and beneficial survival response. It is initiated by damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs), intensified by immune cells itself and mainly ruled by tumour necrosis factor (TNF)α and catecholamines with lactate and hypoxia inducible factor (HIF)-1α as intracellular signals and lactate as an energy shuttle. Important biochemical mechanisms involved in this response are the Warburg effect as an efficient metabolic shortcut and the extended Cori cycle. SUMMARY Stress hyperglycaemia is beneficial in an acute life-threatening situation, but further research is necessary, to prevent trauma patients from the detrimental effects of persisting hyperglycaemia.
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Affiliation(s)
- Christopher Rugg
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schmid
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Zipperle
- Johannes Zipperle, Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Janett Kreutziger
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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2
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Gedeno K, Neme D, Jemal B, Aweke Z, Achule A, Geremu K, Bekele Uddo T. Evidence-based management of adult traumatic brain injury with raised intracranial pressure in intensive critical care unit at resource-limited settings: a literature review. Ann Med Surg (Lond) 2023; 85:5983-6000. [PMID: 38098558 PMCID: PMC10718354 DOI: 10.1097/ms9.0000000000001291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 12/17/2023] Open
Abstract
Background In underdeveloped countries, there is a greater incidence of mortality and morbidity arising from trauma, with traumatic brain injury (TBI) accounting for 50% of all trauma-related deaths. The occurrence of elevated intracranial pressure (ICP), which is a common pathophysiological phenomenon in cases of TBI, acts as a contributing factor to unfavorable outcomes. The aim of this systematic review is to analyze the existing literature regarding the management of adult TBI with raised ICP in an intensive critical care unit, despite limited resources. Methods This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol. Search engines such as PubMed, the Cochrane database, and Google Scholar were utilized to locate high-level evidence that would facilitate the formation of sound conclusions. Result A total of 11 715 articles were identified and individually assessed to determine their eligibility for inclusion or exclusion based on predetermined criteria and outcome variables. The methodological quality of each study was evaluated using recommended criteria. Ultimately, the review consisted of 51 articles. Conclusion Physical examination results and noninvasive assessments of the optic nerve sheath diameter (ONSD) via sonography are positively associated with elevated ICP, and are employed as diagnostic and monitoring tools for elevated ICP in resource-limited settings. Management of elevated ICP necessitates an algorithmic approach that utilizes prophylactic measures and acute intervention treatments to mitigate the risk of secondary brain injury.
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Affiliation(s)
- Kanbiro Gedeno
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | | | | | - Zemedu Aweke
- Department of Anesthesia
- School of Clinical Science, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Astemamagn Achule
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Kuchulo Geremu
- Department of Anesthesia, College of Medicine and Health Science, Arba Minch University, Arba Minch
| | - Tesfanew Bekele Uddo
- Department of Surgery, College of Medicine and Health Science, Dilla University, Dilla, Ethiopia
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3
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Sharma H, McGinnis JP, Kabotyanski KE, Gopinath SP, Goodman JC, Robertson C, Cruz Navarro J. Cerebral microdialysis and glucopenia in traumatic brain injury: A review. Front Neurol 2023; 14:1017290. [PMID: 36779054 PMCID: PMC9911651 DOI: 10.3389/fneur.2023.1017290] [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: 08/11/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
Traditionally, intracranial pressure (ICP) and partial brain tissue oxygenation (PbtO2) have been the primary invasive intracranial measurements used to guide management in patients with severe traumatic brain injury (TBI). After injury however, the brain develops an increased metabolic demand which may require an increment in the oxidative metabolism of glucose. Simultaneously, metabolic, and electrical dysfunction can lead to an inability to meet these demands, even in the absence of ischemia or increased intracranial pressure. Cerebral microdialysis provides the ability to accurately measure local concentrations of various solutes including lactate, pyruvate, glycerol and glucose. Experimental and clinical data demonstrate that such measurements of cellular metabolism can yield critical missing information about a patient's physiologic state and help limit secondary damage. Glucose management in traumatic brain injury is still an unresolved question. As cerebral glucose metabolism may be uncoupled from systemic glucose levels due to the metabolic dysfunction, measurement of cerebral extracellular glucose concentrations could provide more predictive information and prove to be a better biomarker to avoid secondary injury of at-risk brain tissue. Based on data obtained from cerebral microdialysis, specific interventions such as ICP-directed therapy, blood glucose increment, seizure control, and/or brain oxygen optimization can be instituted to minimize or prevent secondary insults. Thus, microdialysis measurements of parenchymal metabolic function provides clinically valuable information that cannot be obtained by other monitoring adjuncts in the standard ICU setting.
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Affiliation(s)
- Himanshu Sharma
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States,*Correspondence: Himanshu Sharma ✉
| | - John P. McGinnis
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | | | - Shankar P. Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jerry C. Goodman
- Department of Pathology, Baylor College of Medicine, Houston, TX, United States
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jovany Cruz Navarro
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States,Department of Anesthesiology, Baylor College of Medicine, Houston, TX, United States
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Saberian S, Mustroph CM, Atif F, Stein D, Yousuf S. Traumatic Brain Injury as a Potential Risk Factor for Diabetes Mellitus in the Veteran Population. Cureus 2022; 14:e27296. [PMID: 36043003 PMCID: PMC9407677 DOI: 10.7759/cureus.27296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/05/2022] Open
Abstract
This review examines various aspects of traumatic brain injury (TBI) and its potential role as a causative agent for type 2 diabetes mellitus (T2DM) in the veteran population. The pituitary glands and the hypothalamus, both housed in the intracranial space, are the most important structures for the homeostatic regulation of almost every hormone in the human body. As such, TBI not only causes psychological and cognitive impairments but can also disrupt the endocrine system. It is well established that in addition to having a high prevalence of chronic traumatic encephalopathy (CTE), veterans have a very high risk of developing various chronic medical conditions. Unfortunately, there are no measures or prophylactic agents that can have a meaningful impact on this medically complex patient population. In this review, we explore several important factors pertaining to both acute and chronic TBI that can provide additional insight into why veterans tend to develop T2DM later in life. We focus on the unique combination of risk factors in this population not typically found in civilians or other individuals with a non-military background. These include post-traumatic stress disorder, CTE, and environmental factors relating to occupation and lifestyle.
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5
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See KC. Glycemic targets in critically ill adults: A mini-review. World J Diabetes 2021; 12:1719-1730. [PMID: 34754373 PMCID: PMC8554370 DOI: 10.4239/wjd.v12.i10.1719] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/06/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023] Open
Abstract
Illness-induced hyperglycemia impairs neutrophil function, increases pro-inflammatory cytokines, inhibits fibrinolysis, and promotes cellular damage. In turn, these mechanisms lead to pneumonia and surgical site infections, prolonged mechanical ventilation, prolonged hospitalization, and increased mortality. For optimal glucose control, blood glucose measurements need to be done accurately, frequently, and promptly. When choosing glycemic targets, one should keep the glycemic variability < 4 mmol/L and avoid targeting a lower limit of blood glucose < 4.4 mmol/L. The upper limit of blood glucose should be set according to casemix and the quality of glucose control. A lower glycemic target range (i.e., blood glucose 4.5-7.8 mmol/L) would be favored for patients without diabetes mellitus, with traumatic brain injury, or who are at risk of surgical site infection. To avoid harm from hypoglycemia, strict adherence to glycemic control protocols and timely glucose measurements are required. In contrast, a higher glycemic target range (i.e., blood glucose 7.8-10 mmol/L) would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus. These targets may be modified if technical advances for blood glucose measurement and control can be achieved.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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6
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Acosta JA, Fernández Ortega JF, Pérez Quesada S. Recommendations for specialized nutritional-metabolic treatment of the critical patient: Neurocritical patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units. Med Intensiva 2021; 44 Suppl 1:69-72. [PMID: 32532415 DOI: 10.1016/j.medin.2020.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 11/26/2022]
Affiliation(s)
- J A Acosta
- Hospital General Universitario de Alicante, Alicante, España.
| | | | - S Pérez Quesada
- Hospital General Universitario de Alicante, Alicante, España
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8
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Svedung Wettervik TM, Lewén A, Enblad P. Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care-Indicative Observations and Future Perspectives. Front Neurol 2021; 12:638132. [PMID: 33716941 PMCID: PMC7943830 DOI: 10.3389/fneur.2021.638132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/20/2021] [Indexed: 01/01/2023] Open
Abstract
Neurointensive care (NIC) has contributed to great improvements in clinical outcomes for patients with severe traumatic brain injury (TBI) by preventing, detecting, and treating secondary insults and thereby reducing secondary brain injury. Traditional NIC management has mainly focused on generally applicable escalated treatment protocols to avoid high intracranial pressure (ICP) and to keep the cerebral perfusion pressure (CPP) at sufficiently high levels. However, TBI is a very heterogeneous disease regarding the type of injury, age, comorbidity, secondary injury mechanisms, etc. In recent years, the introduction of multimodality monitoring, including, e.g., pressure autoregulation, brain tissue oxygenation, and cerebral energy metabolism, in addition to ICP and CPP, has increased the understanding of the complex pathophysiology and the physiological effects of treatments in this condition. In this article, we will present some potential future approaches for more individualized patient management and fine-tuning of NIC, taking advantage of multimodal monitoring to further improve outcome after severe TBI.
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Affiliation(s)
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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9
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High Arterial Glucose is Associated with Poor Pressure Autoregulation, High Cerebral Lactate/Pyruvate Ratio and Poor Outcome Following Traumatic Brain Injury. Neurocrit Care 2020; 31:526-533. [PMID: 31123993 PMCID: PMC6872512 DOI: 10.1007/s12028-019-00743-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Arterial hyperglycemia is associated with poor outcome in traumatic brain injury (TBI), but the pathophysiology is not completely understood. Previous preclinical and clinical studies have indicated that arterial glucose worsens pressure autoregulation. The aim of this study was to evaluate the relationship of arterial glucose to both pressure reactivity and cerebral energy metabolism. Method This retrospective study was based on 120 patients with severe TBI treated at the Uppsala University hospital, Sweden, 2008–2018. Data from cerebral microdialysis (glucose, pyruvate, and lactate), arterial glucose, and pressure reactivity index (PRx55-15) were analyzed the first 3 days post-injury. Results High arterial glucose was associated with poor outcome/Glasgow Outcome Scale-Extended at 6-month follow-up (r = − 0.201, p value = 0.004) and showed a positive correlation with both PRx55-15 (r = 0.308, p = 0.001) and cerebral lactate/pyruvate ratio (LPR) days 1–3 (r = 0. 244, p = 0.014). Cerebral lactate-to-pyruvate ratio and PRx55-15 had a positive association day 2 (r = 0.219, p = 0.048). Multivariate linear regression analysis showed that high arterial glucose predicted poor pressure autoregulation on days 1 and 2. Conclusions High arterial glucose was associated with poor outcome, poor pressure autoregulation, and cerebral energy metabolic disturbances. The latter two suggest a pathophysiological mechanism for the negative effect of arterial hyperglycemia, although further studies are needed to elucidate if the correlations are causal or confounded by other factors.
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Abstract
PURPOSE OF REVIEW To provide an update of glycemic management during metabolic stress related to surgery or critical illness. RECENT FINDINGS There is a clear association between severe hyperglycemia, hypoglycemia, and high glycemic variability and poor outcomes of postoperative or critically ill patients. However, the impressive beneficial effects of tight glycemic management (TGM) by intensive insulin therapy reported in one study were never reproduced. Hence, the recommendation of TGM is now replaced by more liberal blood glucose (BG) targets (< 180 mg/dL or 10 mM). Recent data support the concept of targeting individualized blood glucose (BG) values according to the presence of diabetes mellitus/chronic hyperglycemia, the presence of brain injury, and the time from injury. A more liberal glycemic management goal is currently advised during metabolic stress and could be switched to individualized glycemic management once validated by prospective trials.
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Affiliation(s)
- Wasineenart Mongkolpun
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bruna Provenzano
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
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11
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[Neuroprotection in neurocritical care]. Med Klin Intensivmed Notfmed 2019; 114:635-641. [PMID: 31463676 DOI: 10.1007/s00063-019-00608-8] [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: 06/25/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
In intensive care medicine neuroprotection is understood mostly as various measures to avoid secondary brain damage after initial trauma, as in stroke, intracranial hemorrhage and resuscitation. Every brain trauma differs in the damage pattern and dynamics depending on the primary form of injury. Therefore, there are targeted treatment approaches depending on the pathophysiology of the medical condition. In addition, neuroprotective methods are desirable that are effective in the majority of patients with acute brain injury. In actual fact, in all forms of acute brain injury certain pathophysiological courses are encountered, which can lead to secondary brain damage depending on the intensity, e.g. reperfusion injury, damage to the blood-brain barrier and excitotoxicity. There is evidence to suggest that the creation of physiologically normal conditions leads to a favorable situation for the damaged brain. This article firstly describes the relevance of neuroprotective measures in neurocritical care medicine. Subsequently, general pathophysiological mechanisms in brain trauma are described. Following this, the pathophysiology and treatment options in brain pressure crises (reduction of intracranial pressure), anemia (transfusion management), hyperglycemia and hypoglycemia (adjustment of the blood sugar level) are dealt with. Finally, the use and benefits of therapeutic hypothermia are discussed. This has a special position as the only clinically effective individual measure for neuroprotection. The focus here is on the application following circulatory and cardiac arrest and resuscitation.
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12
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Eisenberg HM, Shenton ME, Pasternak O, Simard JM, Okonkwo DO, Aldrich C, He F, Jain S, Hayman EG. Magnetic Resonance Imaging Pilot Study of Intravenous Glyburide in Traumatic Brain Injury. J Neurotrauma 2019; 37:185-193. [PMID: 31354055 PMCID: PMC6921286 DOI: 10.1089/neu.2019.6538] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pre-clinical studies of traumatic brain injury (TBI) show that glyburide reduces edema and hemorrhagic progression of contusions. We conducted a small Phase II, three-institution, randomized placebo-controlled trial of subjects with TBI to assess the safety and efficacy of intravenous (IV) glyburide. Twenty-eight subjects were randomized and underwent a 72-h infusion of IV glyburide or placebo, beginning within 10 h of trauma. Of the 28 subjects, 25 had Glasgow Coma Scale (GCS) scores of 6-10, and 14 had contusions. There were no differences in adverse events (AEs) or severe adverse events (ASEs) between groups. The magnetic resonance imaging (MRI) percent change at 72-168 h from screening/baseline was compared between the glyburide and placebo groups. Analysis of contusions (7 per group) showed that lesion volumes (hemorrhage plus edema) increased 1036% with placebo versus 136% with glyburide (p = 0.15), and that hemorrhage volumes increased 11.6% with placebo but decreased 29.6% with glyburide (p = 0.62). Three diffusion MRI measures of edema were quantified: mean diffusivity (MD), free water (FW), and tissue MD (MDt), corresponding to overall, extracellular, and intracellular water, respectively. The percent change with time for each measure was compared in lesions (n = 14) versus uninjured white matter (n = 24) in subjects receiving placebo (n = 20) or glyburide (n = 18). For placebo, the percent change in lesions for all three measures was significantly different compared with uninjured white matter (analysis of variance [ANOVA], p < 0.02), consistent with worsening of edema in untreated contusions. In contrast, for glyburide, the percent change in lesions for all three measures was not significantly different compared with uninjured white matter. Further study of IV glyburide in contusion TBI is warranted.
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Affiliation(s)
- Howard M Eisenberg
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Martha E Shenton
- Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Research and Development, VA Boston Healthcare System, Brockton Division, Brockton, Massachusetts
| | - Ofer Pasternak
- Departments of Psychiatry and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christina Aldrich
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Feng He
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Erik G Hayman
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
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13
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Pappacena S, Bailey M, Cabrini L, Landoni G, Udy A, Pilcher DV, Young P, Bellomo R. Early dysglycemia and mortality in traumatic brain injury and subarachnoid hemorrhage. Minerva Anestesiol 2019; 85:830-839. [PMID: 30735020 DOI: 10.23736/s0375-9393.19.13307-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) are the most common causes of severe acute brain injury in younger Intensive Care Unit (ICU) patients. Dysglycemia (abnormal peak glycemia, glycemic variability, mean glycemia, nadir glycemia) is common in these patients but its comparative outcome associations are unclear. METHODS In a retrospective, cross-sectional, study of adults admitted to Australian and New Zealand ICUs with TBI and SAH from 2005 to 2015, we studied the relationship between multiple aspects of early (first 24 hours) dysglycemia and mortality and compared TBI and SAH patients with the general ICU population and with each other. RESULTS Among 670,301 patients, 11,812 had TBI and 6,098 had SAH. After adjustment for illness severity, we found that the mortality rate increased with each quintile of glycemia for each aspect of early dysglycemia (peak glycemia, glycemic variability, mean glycemia, nadir glycemia; P<0.0001 for all). This increased risk of death was greater in TBI and SAH patients than in the general ICU population. Moreover, it was stronger for mean glycemia (increase in mortality from 9.2% in the lowest quintile to 15.1% in general ICU patients compared with an increase in mortality from 4.4% to 49.0% for TBI and SAH patients; P<0.0001). Finally, in TBI patients, this relationship was significantly stronger than in SAH patients (P<0.0001). CONCLUSIONS In TBI and SAH patients, greater dysglycemia is associated with greater mortality. This association is significantly stronger than in the general population and it is significantly stronger in patients with TBI compared with SAH.
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Affiliation(s)
- Simone Pappacena
- Department of Anesthesiology and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Luca Cabrini
- Department of Anesthesiology and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesiology and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care, Alfred Hospital, Melbourne, Australia
| | - David V Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care, Alfred Hospital, Melbourne, Australia
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia - .,School of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Austin Hospital, Melbourne, Australia
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14
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Lheureux O, Prevedello D, Preiser JC. Update on glucose in critical care. Nutrition 2018; 59:14-20. [PMID: 30415158 DOI: 10.1016/j.nut.2018.06.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/08/2018] [Accepted: 06/10/2018] [Indexed: 01/04/2023]
Abstract
The aim of this review is to summarize recent developments on the mechanisms involved in stress hyperglycemia associated with critical illness. Different aspects of the consequences of stress hyperglycemia as well as the therapeutic approaches tested so far are discussed: the physiological regulations of blood glucose, the mechanisms underlying stress hyperglycemia, the clinical associations, and the results of the prospective trials and meta-analyses to be taken into consideration when interpreting the available data. Current recommendations, challenges, and technological hopes for the future are be discussed.
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Affiliation(s)
- Olivier Lheureux
- Department of Intensive Care, CUB-Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Danielle Prevedello
- Department of Intensive Care, CUB-Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, CUB-Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.
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15
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Olariu E, Pooley N, Danel A, Miret M, Preiser JC. A systematic scoping review on the consequences of stress-related hyperglycaemia. PLoS One 2018; 13:e0194952. [PMID: 29624594 PMCID: PMC5889160 DOI: 10.1371/journal.pone.0194952] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/13/2018] [Indexed: 01/04/2023] Open
Abstract
Background Stress-related hyperglycaemia (SHG) is commonly seen in acutely ill patients and has been associated with poor outcomes in many studies performed in different acute care settings. We aimed to review the available evidence describing the associations between SHG and different outcomes in acutely ill patients admitted to an ICU. Study designs, populations, and outcome measures used in observational studies were analysed. Methods We conducted a systematic scoping review of observational studies following the Joanna Briggs methodology. Medline, Embase, and the Cochrane Library were searched for publications between January 2000 and December 2015 that reported on SHG and mortality, infection rate, length of stay, time on ventilation, blood transfusions, renal replacement therapy, or acquired weakness. Results The search yielded 3,063 articles, of which 43 articles were included (totalling 536,476 patients). Overall, the identified studies were heterogeneous in study conduct, SHG definition, blood glucose measurements and monitoring, treatment protocol, and outcome reporting. The most frequently reported outcomes were mortality (38 studies), ICU and hospital length of stay (23 and 18 studies, respectively), and duration of mechanical ventilation (13 studies). The majority of these studies (40 studies) compared the reported outcomes in patients who experienced SHG with those who did not. Fourteen studies (35.9%) identified an association between hyperglycaemia and increased mortality (odds ratios ranging from 1.13 to 2.76). Five studies identified hyperglycaemia as an independent risk factor for increased infection rates, and one identified it as an independent predictor of increased ICU length of stay. Discussion SHG was consistently associated with poor outcomes. However, the wide divergences in the literature mandate standardisation of measuring and monitoring SHG and the creation of a consensus on SHG definition. A better comparability between practices will improve our knowledge on SHG consequences and management.
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Affiliation(s)
| | | | | | | | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
- * E-mail:
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16
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Núñez-Patiño RA, Zorrilla-Vaca A, Rivera-Lara L. Comparison of intensive versus conventional insulin therapy in traumatic brain injury: a meta-analysis of randomized controlled trials. Brain Inj 2018; 32:693-703. [PMID: 29580096 DOI: 10.1080/02699052.2018.1457181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare intensive insulin therapy (IIT) and conventional insulin therapy (CIT) on clinical outcomes of patients with traumatic brain injury (TBI). METHODS MEDLINE, EMBASE, Google Scholar, ISI Web of Science, and Cochrane Library were systematically searched for randomized controlled trials (RCTs) comparing IIT to CIT in patients with TBI. Study-level characteristics, intensive care unit (ICU) events, and long-term functional outcomes were extracted from the articles. Meta-analysis was performed with random-effect models. RESULTS Seven RCTs comprising 1070 patients were included. Although IIT was associated with better neurologic outcome (GOS > 3) (RR=0.87, 95% CI=0.78-0.97; P=0.01; I2=0%), sensitivity analysis revealed that one study influenced this overall estimate (RR=0.90, 95% CI=0.80-1.01, P=0.07; I2=0%). IIT was strongly associated with higher risk of hypoglycaemia (RR=5.79, 95% CI=3.27-10.26, P<0.01; I2=38%). IIT and CIT did not differ in terms of early or late mortality (RR=0.96, 95% CI=0.79-1.17, P=0.7; I2=0%), infection rate (RR=0.82, 95% CI=0.59-1.14, P=0.23; I2=68%), or ICU length of stay (SMD= -0.14, 95% CI=-0.35 to 0.07, P=0.18; I2=45%0.) Conclusions: IIT did not improve long-term neurologic outcome, mortality, or infection rate and was associated with increased risk of hypoglycaemia. Additional well-designed RCTs with defined TBI subgroups should be performed to generate more powerful conclusions.
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Affiliation(s)
- Rafael A Núñez-Patiño
- a Faculty of Health Sciences. School of Medicine , Pontificia Universidad Javeriana , Cali , Colombia
| | - Andres Zorrilla-Vaca
- b Department of Anesthesiology and Critical Care Medicine , The Johns Hopkins Hospital , Baltimore , Maryland , USA.,c Faculty of Health , Universidad del Valle, Hospital Universitario del Valle , Cali , Colombia
| | - Lucia Rivera-Lara
- b Department of Anesthesiology and Critical Care Medicine , The Johns Hopkins Hospital , Baltimore , Maryland , USA.,d Department of Neurology , Johns Hopkins University , Baltimore , Maryland , USA
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Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management. Curr Treat Options Neurol 2018; 20:1. [PMID: 29397452 DOI: 10.1007/s11940-018-0486-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated. RECENT FINDINGS The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.
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Cerebrospinal fluid and brain extracellular fluid in severe brain trauma. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:237-258. [DOI: 10.1016/b978-0-12-804279-3.00014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Oh H, Lee K, Shin S, Seo W. Temporal Patterns and Influential Factors of Blood Glucose Levels During the First 10-Day Critical Period After Brain Injury. Clin Nurs Res 2017; 28:744-761. [PMID: 29254374 DOI: 10.1177/1054773817749725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study was conducted to document temporal patterns of blood glucose level changes during the first 10-day critical period and to identify factors that influence stress-induced hyperglycemia development in brain injury patients. The medical records of 190 brain injury patients were retrospectively reviewed. Blood glucose levels in the poor recovery group were significantly higher than in the good recovery group, particularly during the first 72 hr (158-172 mg/dl). The poor recovery group showed persistent, fluctuating hyperglycemia, whereas the good recovery group exhibited hyperglycemic peaks during the first 3 days that subsequently reduced linearly to normal. Gender, preexisting hypertension, disease severity at admission, total calorie intake, and steroid use were found to influence stress-induced hyperglycemia development significantly. In conclusion, close monitoring and adjustment are required to maintain safe blood glucose levels and the development of protocols for safe glycemic management is essential to improve critical care in brain injury patients.
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Affiliation(s)
- HyunSoo Oh
- 1 Inha University, Incheon, Republic of Korea
| | - KangIm Lee
- 1 Inha University, Incheon, Republic of Korea
| | | | - WhaSook Seo
- 1 Inha University, Incheon, Republic of Korea
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Krinsley JS, Chase JG, Gunst J, Martensson J, Schultz MJ, Taccone FS, Wernerman J, Bohe J, De Block C, Desaive T, Kalfon P, Preiser JC. Continuous glucose monitoring in the ICU: clinical considerations and consensus. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:197. [PMID: 28756769 PMCID: PMC5535285 DOI: 10.1186/s13054-017-1784-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Glucose management in intensive care unit (ICU) patients has been a matter of debate for almost two decades. Compared to intermittent monitoring systems, continuous glucose monitoring (CGM) can offer benefit in the prevention of severe hyperglycemia and hypoglycemia by enabling insulin infusions to be adjusted more rapidly and potentially more accurately because trends in glucose concentrations can be more readily identified. Increasingly, it is apparent that a single glucose target/range may not be optimal for all patients at all times and, as with many other aspects of critical care patient management, a personalized approach to glucose control may be more appropriate. Here we consider some of the evidence supporting different glucose targets in various groups of patients, focusing on those with and without diabetes and neurological ICU patients. We also discuss some of the reasons why, despite evidence of benefit, CGM devices are still not widely employed in the ICU and propose areas of research needed to help move CGM from the research arena to routine clinical use.
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Affiliation(s)
- James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, 06902, USA
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, 8140, New Zealand
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000, Leuven, Belgium
| | - Johan Martensson
- Department of Intensive Care, Austin Hospital, Heidelberg, 3084, VIC, Australia.,Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Marcus J Schultz
- Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesia (L E I C A), Faculty of Tropical Medicine, Mahidol University, Mahidol-Oxford Research Unit (MORU), Bangkok, Thailand
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jan Wernerman
- Karolinska University Hospital Huddinge & Karolinska Institutet, K32 14186, Stockholm, Sweden
| | - Julien Bohe
- Medical Intensive Care Unit, University Hospital of Lyon, Lyon, France
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, B-2650, Edegem, Belgium
| | - Thomas Desaive
- GIGA-In Silico Medicine, Université de Liège, B4000, Liège, Belgium
| | - Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, 28000, Chartres, France
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
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Shi J, Dong B, Mao Y, Guan W, Cao J, Zhu R, Wang S. Review: Traumatic brain injury and hyperglycemia, a potentially modifiable risk factor. Oncotarget 2016; 7:71052-71061. [PMID: 27626493 PMCID: PMC5342608 DOI: 10.18632/oncotarget.11958] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/02/2016] [Indexed: 12/13/2022] Open
Abstract
Hyperglycemia after severe traumatic brain injury (TBI) occurs frequently and is associated with poor clinical outcome and increased mortality. In this review, we highlight the mechanisms that lead to hyperglycemia and discuss how they may contribute to poor outcomes in patients with severe TBI. Moreover, we systematically review the proper management of hyperglycemia after TBI, covering topics such as nutritional support, glucose control, moderated hypothermia, naloxone, and mannitol treatment. However, to date, an optimal and safe glycemic target range has not been determined, and may not be safe to implement among TBI patients. Therefore, there is a mandate to explore a reasonable glycemic target range that can facilitate recovery after severe TBI.
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Affiliation(s)
- Jia Shi
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Bo Dong
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yumin Mao
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Wei Guan
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jiachao Cao
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Rongxing Zhu
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Suinuan Wang
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
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Rostami E. Glucose and the injured brain-monitored in the neurointensive care unit. Front Neurol 2014; 5:91. [PMID: 24936196 PMCID: PMC4047514 DOI: 10.3389/fneur.2014.00091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/23/2014] [Indexed: 12/16/2022] Open
Abstract
Brain has a continuous demand for energy that is met by oxidative metabolism of oxygen and glucose. This demand is compromised in the injured brain and if the inadequate supply persists it will lead to permanent tissue damage. Zero values of cerebral glucose have been associated with infarction and poor neurological outcome. Furthermore, hyperglycemia is common in patients with neurological insults and associated with poor outcome. Intensive insulin therapy (IIT) to control blood glucose has been suggested and used in neurointensive care with conflicting results. This review covers the studies reporting on monitoring of cerebral glucose with microdialysis in patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH) and ischemic stroke. Studies investigating IIT are also discussed. Available data suggest that low cerebral glucose in patients with TBI and SAH provides valuable information on development of secondary ischemia and has been correlated with worse outcome. There is also indication that the location of the catheter is important for correlation between plasma and brain glucose. In conclusion considering catheter location, monitoring of brain glucose in the neurointensive care not only provides information on imminent secondary ischemia it also reveals the effect of peripheral treatment on the injured brain.
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Affiliation(s)
- Elham Rostami
- Department of Neuroscience, Section of Neurosurgery, Uppsala University , Uppsala , Sweden ; Department of Neuroscience, Karolinska Institutet , Stockholm , Sweden
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Jauch-Chara K, Oltmanns KM. Glycemic control after brain injury: boon and bane for the brain. Neuroscience 2014; 283:202-9. [PMID: 24814022 DOI: 10.1016/j.neuroscience.2014.04.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/22/2014] [Accepted: 04/28/2014] [Indexed: 01/10/2023]
Abstract
Hyperglycemia is a common phenomenon in the early phase of brain injury (BI). The management of blood glucose levels after BI, however, is subject of a growing debate. The occurrence of elevated blood glucose concentrations is linked to increased mortality and worse neurologic outcomes indicating the necessity for therapeutic glucose-lowering. Intensive glucose-lowering therapy, on the other hand, inevitably results in an increased rate of hypoglycemic episodes with detrimental effects on the injured brain. In this review, we give an overview on the current knowledge about causes and pathophysiological consequences of dysglycemia in patients with BI and offer some suggestions for clinical glucose management.
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Affiliation(s)
- K Jauch-Chara
- Division of Psychoneurobiology, Department of Psychiatry and Psychotherapy, University of Luebeck, Luebeck, Germany.
| | - K M Oltmanns
- Division of Psychoneurobiology, Department of Psychiatry and Psychotherapy, University of Luebeck, Luebeck, Germany
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Alvis-Miranda HR, Navas-Marrugo SZ, Velasquez-Loperena RA, Adie-Villafañe RJ, Velasquez-Loperena D, Castellar-Leones SM, Alcala- Cerra G, Pulido-Gutiérrez JC, Rodríguez-Conde JR, Moreno-Moreno MF, M. Rubiano A, Moscote-Salazar LR. Effects of Glycemic Level on Outcome of Patients with Traumatic Brain Injury: A Retrospective Cohort Study. Bull Emerg Trauma 2014; 2:65-71. [PMID: 27162868 PMCID: PMC4771295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 02/25/2014] [Accepted: 03/12/2014] [Indexed: 06/05/2023] Open
Abstract
OBJECTIVE To determine the effects of glycemic level on outcome patients with traumatic brain injury. METHODS From September 2010 to December 2012, all medical records of adult patients with TBI admitted to the Emergency Room of Laura Daniela Clinic in Valledupar City, Colombia, South America were enrolled. Both genders between 18 and 85 years who referred during the first 48 hours after trauma, and their glucose level was determined in the first 24 hours of admission were included. Adults older than 85 years, with absence of Glasgow Coma Scale (GCS) score and a brain Computerized Tomography (CT) scans were excluded. The cut-off value was considered 200 mg/dL to define hyperglycemia. Final GCS, hospital admission duration and complications were compared between normoglycemic and hyperglycemic patients. RESULTS Totally 217 patients were identified with TBI. Considering exclusion criteria, 89 patients remained for analysis. The mean age was 43.0±19.6 years, the mean time of remission was 5.9±9.4 hours, the mean GCS on admission was 10.5±3.6 and the mean blood glucose level in the first 24 hours was 138.1±59.4 mg/dL. Hyperglycemia was present in 13.5% of patients. The most common lesions presented by patients with TBI were fractures (22.5%), hematoma (18.3%), cerebral edema (18.3%) and cerebral contusion (16.2%). Most of patients without a high glucose level at admission were managed only medically, whereas surgical treatment was more frequent in patients with hyperglycemia (p=0.042). Hyperglycemia was associated with higher complication (p=0.019) and mortality rate (p=0.039). GCS was negatively associated with on admission glucose level (r=0.11; p=0.46). CONCLUSION Hyperglycemia in the first 24-hours of TBI is associated with higher rate of surgical intervention, higher complication and mortality rates. So hyperglycemia handling is critical to the outcome of patients with traumatic brain injury.
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Affiliation(s)
| | | | | | | | | | | | - Gabriel Alcala- Cerra
- Department of Neurosurgery, University of Cartagena, Cartagena de Indias, Colombia, South America
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Muehlschlegel S, Carandang R, Ouillette C, Hall W, Anderson F, Goldberg R. Frequency and impact of intensive care unit complications on moderate-severe traumatic brain injury: early results of the Outcome Prognostication in Traumatic Brain Injury (OPTIMISM) Study. Neurocrit Care 2014; 18:318-31. [PMID: 23377884 DOI: 10.1007/s12028-013-9817-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Known predictors of adverse outcomes in patients with moderate-severe TBI (msTBI) explain only a relatively small proportion of patient-related outcomes. The frequency and impact of intensive care unit complications (ICU-COMPL) on msTBI-associated outcomes are poorly understood. METHODS In 213 consecutive msTBI patients admitted to a Level I Trauma Center neuro trauma ICU, twenty-eight ICU-COMPL (21 medical and 7 neurological) were prospectively collected and adjudicated by group consensus, using pre-defined criteria. We determined frequencies, and explored associations of ICU-COMPL and hospital discharge outcomes using multivariable logistic regression. RESULTS The average age of the study sample was 53 years, and the median presenting Glasgow Coma Scale and Injury Severity Scores were 5 and 27, respectively. Hyperglycemia (79%), fever (62%), systemic inflammatory response syndrome (60%), and hypotension requiring vasopressors (42%) were the four most common medical ICU-COMPL. Herniation (39%), intracranial rebleed (39%), and brain edema requiring osmotherapy (37%) were the three most common neurological ICU-COMPL. After adjusting for admission variables, duration of ventilation, and ICU length-of-stay, patients with brain edema (OR 5.8; 95% CI 2, 16.7) had a significantly increased odds for dying during hospitalization whereas patients with hospital-acquired urinary tract infection (UTI) had a decreased odds (OR 0.05; 95% CI 0.005, 0.6). Sensitivity analysis revealed that UTI occurred later, suggesting a non-causal association with survival. Brain herniation (OR 15.7; 95% CI 2.6, 95.4) was associated with an unfavorable functional status (GOS 1-3). CONCLUSION ICU-COMPL are very common after msTBI, have a considerable impact on short-term outcomes, and should be considered in the prognostication of these high risk patients. Survival associations of time-dependent complications warrant cautious interpretation.
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Affiliation(s)
- Susanne Muehlschlegel
- Division of Neurocritical Care, Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.
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SCHIRMER-MIKALSEN K, MOEN KG, SKANDSEN T, VIK A, KLEPSTAD P. Intensive care and traumatic brain injury after the introduction of a treatment protocol: a prospective study. Acta Anaesthesiol Scand 2013; 57:46-55. [PMID: 23095138 DOI: 10.1111/j.1399-6576.2012.02785.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) treatment protocols have been introduced in the intensive care unit (ICU) to avoid secondary brain injury. In this study, we aimed to evaluate the deviations from such a treatment protocol and the frequency of extracranial complications, and relate these findings to outcome. METHODS During a 5-year period (2004-2009), 133 patients with severe TBI [Glasgow Coma Scale (GCS) score ≤ 8] were prospectively included. The following deviations from treatment goals were studied: intracranial pressure (ICP), blood pressure, haemoglobin, blood glucose, serum sodium, serum albumin, body temperature and extracranial complications during the ICU stay. Outcome was assessed using Glasgow Outcome Scale Extended score at 12 months. RESULTS The frequencies of deviations from the treatment goals were: episodes of intracranial hypertension 69.5% (of monitored patients), hypotension 20.3%, anaemia 77.4%, hyperglycaemia 42.9%, hyponatremia 34.6%, hypoalbuminemia 30.8% and hyperthermia 54.9%. Pulmonary complications were common (pneumonia 72.2%, acute respiratory distress syndrome/acute lung injury 31.6%). Thrombocytopenia (4.5%), severe sepsis (3.0%), renal failure (0.8%) and liver failure (0.8%) were infrequent. Twenty-six (19.5%) patients died within the first 12 months due to the head injury. Age, GCS score, pupil dilation, Injury Severity Score (ISS), ICP > 25 mmHg, hyperglycaemia and pneumonia predicted a worse outcome. CONCLUSIONS Deviations from the TBI treatment protocol were frequent. Pneumonia was the most frequent extracranial complication. Age, GCS score, pupil dilation, ISS, high ICP, hyperglycaemia and pneumonia predicted a worse outcome.
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Affiliation(s)
- K. SCHIRMER-MIKALSEN
- Department of Anaesthesia and Acute Medicine; St.Olav University Hospital; Trondheim; Norway
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Ryan CG, Ajam KS, Thompson RE. Neurosurgery. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Crownover J, Galang GNF, Wagner A. Rehabilitation Considerations for Traumatic Brain Injury in the Geriatric Population: Epidemiology, Neurobiology, Prognosis, and Management. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13670-012-0021-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Birnbaum T, Schmid SP, Feddersen B, Schankin CJ, Straube A. "Moderate intensive insulin therapy" is associated with remission of high intracranial pressure in patients with vascular or infectious central nervous system diseases. J Clin Neurosci 2012; 19:727-32. [PMID: 22424800 DOI: 10.1016/j.jocn.2011.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Revised: 04/11/2011] [Accepted: 04/23/2011] [Indexed: 11/16/2022]
Abstract
Intensive insulin therapy (IIT), targeting blood glucose between 80 mg/dL and 110 mg/dL ("strict IIT"), has been associated with rapid remission of high intracranial pressure (ICP), but its use is limited due to a high risk of hypoglycemia. The aim of this retrospective study was to assess whether "moderate IIT" (target range for blood glucose: 80-140 mg/dL) could have the same beneficial effect on ICP with a lower risk of hypoglycemia. We retrospectively analyzed the records of 64 patients with high ICP due to vascular or infectious central nervous system diseases. Patients treated with moderate IIT (n=32) after 2005 were compared with patients treated with a conventional approach (n=32, target <180 mg/dL) before 2005. We assessed daily ICP during the first 14 days. Secondary endpoints were the rate of hypoglycemic events and outcome. ICP was significantly lower during the second week in patients treated with moderate IIT (mean±standard deviation [SD] daily ICP on days 8-14: 16±5 mmHg compared to 12±4 mmHg, p<0.001). The risk of hypoglycemic events (<40 mg/dL) did not differ significantly between the groups (0 vs. 1 patient, p=0.5). Moderate IIT is associated with remission of high ICP. In contrast to strict IIT, its use seems not to be limited by an increased risk of severe hypoglycemia.
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Affiliation(s)
- Tobias Birnbaum
- Department of Neurology, Ludwig-Maximilians-University, Klinikum Großhadern, Marchioninistraße 15, Munich 81377, Germany.
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Perioperative glucose control in neurosurgical patients. Anesthesiol Res Pract 2012; 2012:690362. [PMID: 22400022 PMCID: PMC3286889 DOI: 10.1155/2012/690362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 09/29/2011] [Accepted: 10/21/2011] [Indexed: 02/06/2023] Open
Abstract
Many neurosurgery patients may have unrecognized diabetes or may develop stress-related hyperglycemia in the perioperative period. Diabetes patients have a higher perioperative risk of complications and have longer hospital stays than individuals without diabetes. Maintenance of euglycemia using intensive insulin therapy (IIT) continues to be investigated as a therapeutic tool to decrease morbidity and mortality associated with derangements in glucose metabolism due to surgery. Suboptimal perioperative glucose control may contribute to increased morbidity, mortality, and aggravate concomitant illnesses. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce blood glucose excursions, and prevent hypoglycemia. Differences in cerebral versus systemic glucose metabolism, time course of cerebral response to injury, and heterogeneity of pathophysiology in the neurosurgical patient populations are important to consider in evaluating the risks and benefits of IIT. While extremes of glucose levels are to be avoided, there are little data to support an optimal blood glucose level or recommend a specific use of IIT for euglycemia maintenance in the perioperative management of neurosurgical patients. Individualized treatment should be based on the local level of blood glucose control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered.
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Stover JF. Contemporary view on neuromonitoring following severe traumatic brain injury. World J Crit Care Med 2012; 1:15-22. [PMID: 24701397 PMCID: PMC3956064 DOI: 10.5492/wjccm.v1.i1.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/27/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Evolving brain damage following traumatic brain injury (TBI) is strongly influenced by complex pathophysiologic cascades including local as well as systemic influences. To successfully prevent secondary progression of the primary damage we must actively search and identify secondary insults e.g. hypoxia, hypotension, uncontrolled hyperventilation, anemia, and hypoglycemia, which are known to aggravate existing brain damage. For this, we must rely on specific cerebral monitoring. Only then can we unmask changes which otherwise would remain hidden, and prevent adequate intensive care treatment. Apart from intracranial pressure (ICP) and calculated cerebral perfusion pressure (CPP), extended neuromonitoring (SjvO2, ptiO2, microdialysis, transcranial Doppler sonography, electrocorticography) also allows us to define individual pathologic ICP and CPP levels. This, in turn, will support our therapeutic decision-making and also allow a more individualized and flexible treatment concept for each patient. For this, however, we need to learn to integrate several dimensions with their own possible treatment options into a complete picture. The present review summarizes the current understanding of extended neuromonitoring to guide therapeutic interventions with the aim of improving intensive care treatment following severe TBI, which is the basis for ameliorated outcome.
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Affiliation(s)
- John F Stover
- John F Stover, Surgical Intensive Care Medicine, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
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Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med 2012; 20:12. [PMID: 22304785 PMCID: PMC3298793 DOI: 10.1186/1757-7241-20-12] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 02/03/2012] [Indexed: 01/29/2023] Open
Abstract
Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP.
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Affiliation(s)
- Samir H Haddad
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.
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Griesdale DEG, Tremblay MH, McEwen J, Chittock DR. Glucose control and mortality in patients with severe traumatic brain injury. Neurocrit Care 2011; 11:311-6. [PMID: 19636972 DOI: 10.1007/s12028-009-9249-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The optimal glucose range in patients with severe traumatic brain injury (TBI) remains unclear. The goal of this study was to examine the association of serum glucose levels on mortality in patients with severe TBI. As a secondary endpoint, we determined the risk of hyperglycemic and hypoglycemic events, and their association with mortality. METHODS We conducted a retrospective cohort study of patients admitted to the ICU between May 2000 and March 2006 with severe TBI (Glasgow Coma Scale ≤ 8) who survived at least 12 h. Average daily morning glucose levels for the first 10 days of admission were calculated and divided into quintiles. RESULTS A total of 170 patients were included in the analysis. We found no association between quintiles of mean daily morning glucose and hospital mortality. Episodes of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) during the first 10 days occurred in 65% of patients (5.4% of all glucose measurements). Using multivariable regression, a single episode of hyperglycemia was associated with 3.6-fold increased risk of hospital mortality (95%CI: 1.2-11.2, P = 0.02). Hypoglycemia ( ≤ 4.4 mmol/l or 80 mg/dl) was present in 48% of patients (4.3% of all glucose measurements), and was not associated with mortality. CONCLUSION Any episode of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) was associated with 3.6-fold increased risk of hospital mortality in patients with severe TBI and thus, should be avoided. Maintaining serum glucose ≤ 10 mmol/l appears to be a reasonable balance to avoid extremes of glucose control, but further studies are needed to determine the optimal glucose range.
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Affiliation(s)
- Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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Godoy DA, Di Napoli M, Rabinstein AA. Treating hyperglycemia in neurocritical patients: benefits and perils. Neurocrit Care 2011; 13:425-38. [PMID: 20652767 DOI: 10.1007/s12028-010-9404-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
There is growing debate over the value of intensive insulin therapy (IIT) in critically ill patients. Available trials have been performed in general medical or surgical intensive care units, and the results may not be directly applicable to patients with severe acute brain disease because these patients may have heightened susceptibility to hyperglycemia (HyperG) and hypoglycemia. Our objective was to review the pathophysiology and effects of HyperG and hypoglycemia in neurocritical patients and to analyze the potential role of IIT in this population. Source data were obtained from a PubMed search of the medical literature combining the terms HyperG, hypoglycemia, insulin, stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), spinal cord injury (SCI), and related diagnoses. Brain metabolism is highly dependent on constant supply of glucose. As a consequence, the acutely injured brain is particularly sensitive to hypoglycemia, which can induce a state of energy failure (metabolic crisis). Meanwhile, neurocritical patients have a high prevalence of HyperG, and its occurrence is associated with poor outcome after acute ischemic stroke, ICH, SAH, and TBI. It is unclear whether this association is due to direct detrimental effects exerted by HyperG or simply represents a marker of severe brain injury. Insulin has been shown to have various potentially pleiotropic neuroprotective properties in experimental models. However, the safety and efficacy of IIT in patients with critical brain disease have not been well studied. Available results do not support the use of IIT to maintain strict normoglycemia in this population. Patients with critical brain disease should have frequent glucose monitoring because severe HyperG and even modest hypoglycemia may be detrimental. Careful use of insulin infusion protocols appears advisable, but maintenance of strict normoglycemia cannot be recommended. Rigorous studies must be conducted to assess the value of insulin therapy and to determine the optimal blood glucose targets in patients with the most common acute vascular and traumatic brain insults.
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Affiliation(s)
- Daniel A Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
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Propensity scores in intensive care and anaesthesiology literature: a systematic review. Intensive Care Med 2010; 36:1993-2003. [PMID: 20689924 DOI: 10.1007/s00134-010-1991-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Accepted: 07/08/2010] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Propensity score methods have been increasingly used in the last 10 years. However, the practical use of the propensity score (PS) has been reported as heterogeneous in several papers reviewing the use of propensity scores and giving some advice. No precedent work has focused on the specific application of PS in intensive care and anaesthesiology literature. OBJECTIVES After a brief development of the theory of propensity score, to assess the use and the quality of reporting of PS studies in intensive care and anaesthesiology, and to evaluate how past reviews have influenced the quality of the reporting. STUDY DESIGN AND SETTING Forty-seven articles published between 2006 and 2009 in the intensive care and anaesthesiology literature were evaluated. We extracted the characteristics of the report, the type of analysis, the details of matching procedures, the number of patients in treated and control groups, and the number of covariates included in the PS models. RESULTS Of the 47 articles reviewed, 26 used matching on PS, 12 used stratification on PS and 9 used adjustment on PS. The method used was reported in 81% of the articles, and the choice to conduct a paired analysis or not was reported in only 15%. The comparison with the previously published reviews showed little improvement in reporting in the last few years. CONCLUSION The quality of reporting propensity scores in intensive care and anaesthesiology literature should be improved. We provide some recommendations to the investigators in order to improve the reporting of PS analyses.
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Flückiger C, Béchir M, Brenni M, Ludwig S, Sommerfeld J, Cottini SR, Keel M, Stocker R, Stover JF. Increasing hematocrit above 28% during early resuscitative phase is not associated with decreased mortality following severe traumatic brain injury. Acta Neurochir (Wien) 2010; 152:627-36. [PMID: 20033233 DOI: 10.1007/s00701-009-0579-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 12/04/2009] [Indexed: 01/10/2023]
Abstract
BACKGROUND To prevent iatrogenic damage, transfusions of red blood cells should be avoided. For this, specific and reliable transfusion triggers must be defined. To date, the optimal hematocrit during the initial operating room (OR) phase is still unclear in patients with severe traumatic brain injury (TBI). We hypothesized that hematocrit values exceeding 28%, the local hematocrit target reached by the end of the initial OR phase, resulted in more complications, increased mortality, and impaired recovery compared to patients in whom hematocrit levels did not exceed 28%. METHODS Impact of hematocrit (independent variable) reached by the end of the OR phase on mortality and morbidity determined by the extended Glasgow outcome scale (eGOS; dependent variables) was investigated retrospectively in 139 TBI patients. In addition, multiple logistic regression analysis was performed to identify additional important variables. FINDINGS Following severe TBI, mortality and morbidity were neither aggravated by hematocrit above 28% reached by the end of the OR phase nor worsened by the required transfusions. Upon multiple logistic regression analysis, eGOS was significantly influenced by the highest intracranial pressure and the lowest cerebral perfusion pressure values during the initial OR phase. CONCLUSIONS Based on this retrospective observational analysis, increasing hematocrit above 28% during the initial OR phase following severe TBI was not associated with improved or worsened outcome. This questions the need for aggressive transfusion management. Prospective analysis is required to determine the lowest acceptable hematocrit value during the OR phase which neither increases mortality nor impairs recovery. For this, a larger caseload and early monitoring of cerebral metabolism and oxygenation are indispensable.
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Affiliation(s)
- Carole Flückiger
- Surgical Intensive Care Medicine, University Hospital Zürich, 8091 Zürich, Switzerland
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Akhtar S, Barash PG, Inzucchi SE. Scientific principles and clinical implications of perioperative glucose regulation and control. Anesth Analg 2010; 110:478-97. [PMID: 20081134 DOI: 10.1213/ane.0b013e3181c6be63] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Development of hyperglycemia after major operations is very common and is modulated by many factors. These factors include perioperative metabolic state, intraoperative management of the patient, and neuroendocrine stress response to surgery. Acute insulin resistance also develops perioperatively and contributes significantly to hyperglycemia. Hyperglycemia is associated with poor outcomes in critically ill and postsurgical patients. A majority of the investigations use the term "hyperglycemia" very loosely and use varying thresholds for initiating treatment. Initial studies demonstrated improved outcomes in critically ill, postsurgical patients who received intensive glycemic control (IGC) (target serum glucose <110 mg/dL). These results were quickly extrapolated to other clinical areas, and IGC was enthusiastically recommended in the perioperative period. However, there are few studies investigating the value of intraoperative glycemic control. Moreover, recent prospective trials have not been able to show the benefit of IGC; neither an appropriate therapeutic glycemic target nor the true efficacy of perioperative glycemic control has been fully determined. Practitioners should also appreciate technical nuances of various glucose measurement techniques. IGC increases the risk of hypoglycemia significantly, which is not inconsequential in critically ill patients. Until further specific data are accumulated, it is prudent to maintain glucose levels <180 mg/dL in the perioperative period, and glycemic control should always be accompanied by close glucose monitoring.
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Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
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Meierhans R, Béchir M, Ludwig S, Sommerfeld J, Brandi G, Haberthür C, Stocker R, Stover JF. Brain metabolism is significantly impaired at blood glucose below 6 mM and brain glucose below 1 mM in patients with severe traumatic brain injury. Crit Care 2010; 14:R13. [PMID: 20141631 PMCID: PMC2875528 DOI: 10.1186/cc8869] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 12/20/2009] [Accepted: 02/08/2010] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The optimal blood glucose target following severe traumatic brain injury (TBI) must be defined. Cerebral microdialysis was used to investigate the influence of arterial blood and brain glucose on cerebral glucose, lactate, pyruvate, glutamate, and calculated indices of downstream metabolism. METHODS In twenty TBI patients, microdialysis catheters inserted in the edematous frontal lobe were dialyzed at 1 microl/min, collecting samples at 60 minute intervals. Occult metabolic alterations were determined by calculating the lactate- pyruvate (L/P), lactate- glucose (L/Glc), and lactate- glutamate (L/Glu) ratios. RESULTS Brain glucose was influenced by arterial blood glucose. Elevated L/P and L/Glc were significantly reduced at brain glucose above 1 mM, reaching lowest values at blood and brain glucose levels between 6-9 mM (P < 0.001). Lowest cerebral glutamate was measured at brain glucose 3-5 mM with a significant increase at brain glucose below 3 mM and above 6 mM. While L/Glu was significantly increased at low brain glucose levels, it was significantly decreased at brain glucose above 5 mM (P < 0.001). Insulin administration increased brain glutamate at low brain glucose, but prevented increase in L/Glu. CONCLUSIONS Arterial blood glucose levels appear to be optimal at 6-9 mM. While low brain glucose levels below 1 mM are detrimental, elevated brain glucose are to be targeted despite increased brain glutamate at brain glucose >5 mM. Pathogenity of elevated glutamate appears to be relativized by L/Glu and suggests to exclude insulin- induced brain injury.
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Affiliation(s)
- Roman Meierhans
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Markus Béchir
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Silke Ludwig
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Jutta Sommerfeld
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
- Ospedale Maggiore Policlinico Milano, Via Francesco Sforza, 28, I-20122 Milano, Italy
| | - Christoph Haberthür
- Surgical Intensive Care, Luzerner Kantonsspital, 6000 Luzern 16, Switzerland
| | - Reto Stocker
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - John F Stover
- Surgical Intensive Care, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
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Metzger JC, Eastman AL, Pepe PE. Year in review 2008: Critical Care--trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:226. [PMID: 19863766 PMCID: PMC2784337 DOI: 10.1186/cc7960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Eleven papers on trauma published in Critical Care during 2008 addressed traumatic brain injury (TBI), burns, diagnostic concerns and immunosuppression. In regard to TBI, preliminary results indicate the utility of either magnetic resonance imaging (MRI) or ultrasound in measuring optic nerve sheath diameter to identify elevated intracranial pressure (ICP) as well as the potential benefit of thiopental for refractory ICP. Another investigaticc7960on demonstrated that early extubation of TBI patients whose Glasgow Coma Scale score was 8 or less did not result in additional incidence of nosocomial pneumonia. Another study indicated that strict glucose control resulted in worse outcomes during the first week after TBI, but improved outcomes after the second week. Another paper showed the prolonged neuroprotective advantages of proges-terone administration in TBI patients. There was also guidance on improved classifications of renal complications in burn patients. Another study found that patients with inhalation injuries and increased interleukin-6 (IL-6) and IL-10 and decreased IL-7 had increased mortality rates. One literature review described the disadvantages of prolonged immobilization or additional use of MRI for ruling out cervical spine injuries in obtunded TBI patients already cleared by computerized tomography scans. Other investigators found that higher N-terminal pro B-type natriuretic peptide (NT-proBNP) levels may be useful markers for post-traumatic cardiac impairment. Finally, an experimental model showed that both splenic apoptosis and lymphocytopenia may occur shortly after severe hemorrhage, thus increasing the threat of immunosuppression in those with severe blood loss.
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Affiliation(s)
- Jeffery C Metzger
- Department of Surgery, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Mail Code 8579, Dallas, TX 75390-8579, USA.
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Marion DW. Optimum serum glucose levels for patients with severe traumatic brain injury. F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948739 PMCID: PMC2924725 DOI: 10.3410/m1-42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Tight glucose control during the acute care of patients with severe traumatic brain injury has recently been advocated based on experimental concerns about deleterious effects of presenting the injured brain with a high glucose load, however, there is little or no clinical evidence that hyperglycemia worsens neurologic injury. The majority of the clinical studies of tight glucose control find that it is associated with an increased risk of hypoglycemic episodes and cellular injury, when compared to conventional glucose control protocols.
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Affiliation(s)
- Donald W Marion
- Department of Neurosurgery, University of New Mexico School of MedicineAlbuquerque, NM 87131-0001USA
- 35 High Rock Road, Wayland, MA 01778USA
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Holbein M, Béchir M, Ludwig S, Sommerfeld J, Cottini SR, Keel M, Stocker R, Stover JF. Differential influence of arterial blood glucose on cerebral metabolism following severe traumatic brain injury. Crit Care 2009; 13:R13. [PMID: 19196488 PMCID: PMC2688130 DOI: 10.1186/cc7711] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 12/01/2008] [Accepted: 02/06/2009] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Maintaining arterial blood glucose within tight limits is beneficial in critically ill patients. Upper and lower limits of detrimental blood glucose levels must be determined. METHODS In 69 patients with severe traumatic brain injury (TBI), cerebral metabolism was monitored by assessing changes in arterial and jugular venous blood at normocarbia (partial arterial pressure of carbon dioxide (paCO2) 4.4 to 5.6 kPa), normoxia (partial arterial pressure of oxygen (paO2) 9 to 20 kPa), stable haematocrit (27 to 36%), brain temperature 35 to 38 degrees C, and cerebral perfusion pressure (CPP) 70 to 90 mmHg. This resulted in a total of 43,896 values for glucose uptake, lactate release, oxygen extraction ratio (OER), carbon dioxide (CO2) and bicarbonate (HCO3) production, jugular venous oxygen saturation (SjvO2), oxygen-glucose index (OGI), lactate-glucose index (LGI) and lactate-oxygen index (LOI). Arterial blood glucose concentration-dependent influence was determined retrospectively by assessing changes in these parameters within pre-defined blood glucose clusters, ranging from less than 4 to more than 9 mmol/l. RESULTS Arterial blood glucose significantly influenced signs of cerebral metabolism reflected by increased cerebral glucose uptake, decreased cerebral lactate production, reduced oxygen consumption, negative LGI and decreased cerebral CO2/HCO3 production at arterial blood glucose levels above 6 to 7 mmol/l compared with lower arterial blood glucose concentrations. At blood glucose levels more than 8 mmol/l signs of increased anaerobic glycolysis (OGI less than 6) supervened. CONCLUSIONS Maintaining arterial blood glucose levels between 6 and 8 mmol/l appears superior compared with lower and higher blood glucose concentrations in terms of stabilised cerebral metabolism. It appears that arterial blood glucose values below 6 and above 8 mmol/l should be avoided. Prospective analysis is required to determine the optimal arterial blood glucose target in patients suffering from severe TBI.
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Affiliation(s)
- Monika Holbein
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Silke Ludwig
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Jutta Sommerfeld
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Silvia R Cottini
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Marius Keel
- Department of Surgery, Division of Trauma Surgery, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - Reto Stocker
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
| | - John F Stover
- Surgical Intensive Care Medicine, University Hospital Zuerich, Raemistrasse 100, Zuerich, 8091, Switzerland
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Vespa PM. Intensive glycemic control in traumatic brain injury: what is the ideal glucose range? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:175. [PMID: 18771578 PMCID: PMC2592729 DOI: 10.1186/cc6986] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Intensive glycemic control has become standard practice. Existing data, however, suggest this practice may have adverse consequences for traumatic brain injury. The recent paper by Meier and colleagues suggests that intensive glycemic control may be deleterious. The present article explores existing literature surrounding this controversy, and outlines the literature that raises concern. Finally, I suggest an alternative course of action that may enable control of glucose in an optimal range.
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Affiliation(s)
- Paul M Vespa
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, 757 Westwood Blvd, Suite 6236A, Los Angeles, CA 90095, USA.
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