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Li F, Qin N, Yu Y, Dong R, Li X, Gong S, Zeng Z, Huang L, Yang H. TREM-1 inhibition or ondansetron administration ameliorates NLRP3 inflammasome and pyroptosis in traumatic brain injury-induced acute lung injury. Arch Med Sci 2024; 20:984-996. [PMID: 39050170 PMCID: PMC11264077 DOI: 10.5114/aoms/174264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/17/2023] [Indexed: 07/27/2024] Open
Abstract
Introduction Recently, NLR family pyrin domain containing 3 (NLRP3) and pyroptosis have been reported to be involved in traumatic brain injury-induced acute lung injury (TBI-ALI). Studies have shown that triggering receptor expressed on myeloid cells-1 (TREM-1) may be one of the upstream molecules regulating NLRP3/pyroptosis, and 5-hydroxytryptamine type 3-receptor (5-HT3R) antagonists can inhibit NLRP3/pyroptosis. However, the role of TRME-1 in TBI-ALI, the therapeutic effect of 5-HT3R inhibition on TBI-ALI and its mechanism are still unclear. Therefore, this study aimed to evaluate the protective effect of ondansetron, a 5-HT3 inhibitor, on TBI-ALI, and to explore whether the underlying mechanism is related to the regulation of TREM-1. Material and methods A TBI-ALI rat model was constructed via lateral fluid percussion (LFP) brain injury, and either TREM-1 inhibitor (LP17) or ondansetron was administered as needed. Results TBI induced NLRP3 inflammasome, pyroptosis, and TREM-1 activation in rat lung tissues in a time-dependent manner. Inhibition of TREM-1 activity attenuated TBI-ALI; this is evident from reduced pathological scores, wet/dry ratios, and bronchoalveolar lavage fluid protein levels and alleviated NLRP3 inflammasome/pyroptosis. In addition, ondansetron reduced NLRP3 inflammasome/pyroptosis and alleviated TBI-ALI. Moreover, ondansetron reduced TREM-1 activation in macrophages and lung tissue. Conclusions Ondansetron alleviated TBI-ALI. In terms of mechanism, TREM-1 promotes TBI-ALI via the NLRP3-related pyroptosis pathway, and the protective effect of ondansetron on TBI-ALI may be related to the inhibition of TREM-1.
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Affiliation(s)
- Fen Li
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
| | - Na Qin
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
| | - Yiqin Yu
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
| | - Rui Dong
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
| | - Xiaojie Li
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
| | - Shenhai Gong
- School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangzhou, China
| | - Lin Huang
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangzhou, China
| | - Hong Yang
- Department of Critical Care Medicine, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
- The Third Clinical College of Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation, Guangzhou, China
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Wang RH, Lu AL, Li HP, Ma ZH, Wu SB, Lu HJ, Wen WX, Huang Y, Wang LX, Yuan F. Prevalence, predictors, and outcomes of acute respiratory distress syndrome in severe stroke. Neurol Sci 2024; 45:2719-2728. [PMID: 38150131 DOI: 10.1007/s10072-023-07269-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/14/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES Patients with severe stroke are at high risk of developing acute respiratory distress syndrome (ARDS), but this severe complication was often under-diagnosed and rarely explored in stroke patients. We aimed to investigate the prevalence, early predictors, and outcomes of ARDS in severe stroke. METHODS This prospective study included consecutive patients admitted to neurological intensive care unit (neuro-ICU) with severe stroke, including acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The incidence of ARDS was examined, and baseline characteristics and severity scores on admission were investigated as potential early predictors for ARDS. The in-hospital mortality, length of neuro-ICU stay, the total cost in neuro-ICU, and neurological functions at 90 days were explored. RESULTS Of 140 patients included, 35 (25.0%) developed ARDS. Over 90% of ARDS cases occurred within 1 week of admission. Procalcitonin (OR 1.310 95% CI 1.005-1.707, P = 0.046) and PaO2/FiO2 on admission (OR 0.986, 95% CI 0.979-0.993, P < 0.001) were independently associated with ARDS, and high brain natriuretic peptide (OR 0.994, 95% CI 0.989-0.998, P = 0.003) was a red flag biomarker warning that the respiratory symptoms may be caused by cardiac failure rather than ARDS. ARDS patients had longer stays and higher expenses in neuro-ICU. Among patients with ARDS, 25 (62.5%) were moderate or severe ARDS. All the patients with moderate to severe ARDS had an unfavorable outcome at 90 days. CONCLUSIONS ARDS is common in patients with severe stroke, with most cases occurring in the first week of admission. Procalcitonin and PaO2/FiO2 on admission are early predictors of ARDS. ARDS worsens both short-term and long-term outcomes. The conflict in respiratory support strategies between ARDS and severe stroke needs to be further studied.
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Affiliation(s)
- Rui-Hong Wang
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Ai-Li Lu
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hui-Ping Li
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhao-Hui Ma
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shi-Biao Wu
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hong-Ji Lu
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wan-Xin Wen
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan Huang
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Research On Emergency in TCM, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Li-Xin Wang
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China.
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Research On Emergency in TCM, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Guangzhou, Guangdong, China.
| | - Fang Yuan
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China.
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Guangzhou, Guangdong, China.
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Tang C, Huang R. Comment on "Relationship between platelet indices and red cell distribution width and short-term mortality in traumatic brain injury with 30-day mortality". REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20231543. [PMID: 38716953 PMCID: PMC11068372 DOI: 10.1590/1806-9282.20231543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/29/2023] [Indexed: 05/12/2024]
Affiliation(s)
- Changjiu Tang
- Jingmen People's Hospital, Department of Neurosurgery – Jingmen, China
| | - Rong Huang
- Jingmen People's Hospital, Department of Rehabilitation and Physiotherapy – Jingmen, China
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Gandasasmita N, Li J, Loane DJ, Semple BD. Experimental Models of Hospital-Acquired Infections After Traumatic Brain Injury: Challenges and Opportunities. J Neurotrauma 2024; 41:752-770. [PMID: 37885226 DOI: 10.1089/neu.2023.0453] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Patients hospitalized after a moderate or severe traumatic brain injury (TBI) are at increased risk of nosocomial infections, including bacterial pneumonia and other upper respiratory tract infections. Infections represent a secondary immune challenge for vulnerable TBI patients that can lead to increased morbidity and poorer long-term prognosis. This review first describes the clinical significance of infections after TBI, delving into the known mechanisms by which a TBI can alter systemic immunological responses towards an immunosuppressive state, leading to promotion of increased vulnerability to infections. Pulmonary dysfunction resulting from respiratory tract infections is considered in the context of neurotrauma, including the bidirectional relationship between the brain and lungs. Turning to pre-clinical modeling, current laboratory approaches to study experimental TBI and lung infections are reviewed, to highlight findings from the limited key studies to date that have incorporated both insults. Then, practical decisions for the experimental design of animal studies of post-injury infections are discussed. Variables associated with the host animal, the infectious agent (e.g., species, strain, dose, and administration route), as well as the timing of the infection relative to the injury model are important considerations for model development. Together, the purpose of this review is to highlight the significant clinical need for increased pre-clinical research into the two-hit insult of a hospital-acquired infection after TBI to encourage further scientific enquiry in the field.
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Affiliation(s)
| | - Jian Li
- Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - David J Loane
- School of Biochemistry and Immunology, Trinity Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bridgette D Semple
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Prahran, Victoria, Australia
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, Victoria, Australia
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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Chan WH, Huang SM, Chiu YL. Pulmonary Effects of Traumatic Brain Injury in Mice: A Gene Set Enrichment Analysis. Int J Mol Sci 2024; 25:3018. [PMID: 38474264 DOI: 10.3390/ijms25053018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/14/2024] Open
Abstract
Acute lung injury occurs in 20-25% of cases following traumatic brain injury (TBI). We investigated changes in lung transcriptome expression post-TBI using animal models and bioinformatics. Employing unilateral controlled cortical impact for TBI, we conducted microarray analysis after lung acquisition, followed by gene set enrichment analysis of differentially expressed genes. Our findings indicate significant upregulation of inflammation-related genes and downregulation of nervous system genes. There was enhanced infiltration of adaptive immune cells, evidenced by positive enrichment in Lung-Th1, CD4, and CD8 T cells. Analysis using the Tabula Sapiens database revealed enrichment in lung-adventitial cells, pericytes, myofibroblasts, and fibroblasts, indicating potential effects on lung vasculature and fibrosis. Gene set enrichment analysis linked TBI to lung diseases, notably idiopathic pulmonary hypertension. A Venn diagram overlap analysis identified a common set of 20 genes, with FOSL2 showing the most significant fold change. Additionally, we observed a significant increase in ADRA1A→IL6 production post-TBI using the L1000 library. Our study highlights the impact of brain trauma on lung injury, revealing crucial gene expression changes related to immune cell infiltration, cytokine production, and potential alterations in lung vasculature and fibrosis, along with a specific spectrum of disease influence.
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Affiliation(s)
- Wei-Hung Chan
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei City 114201, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei City 114201, Taiwan
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei City 114201, Taiwan
| | - Yi-Lin Chiu
- Department of Biochemistry, National Defense Medical Center, Taipei City 114201, Taiwan
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Taran S, Stevens RD, Perrot B, McCredie VA, Cinotti R, Asehnoune K, Pelosi P, Robba C. Incidence and Outcomes of Acute Respiratory Distress Syndrome in Brain-Injured Patients Receiving Invasive Ventilation: A Secondary Analysis of the ENIO Study. J Intensive Care Med 2024; 39:136-145. [PMID: 37563968 PMCID: PMC10771027 DOI: 10.1177/08850666231194532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Background: Acute respiratory distress syndrome (ARDS) is an important pulmonary complication in brain-injured patients receiving invasive mechanical ventilation (IMV). We aimed to evaluate the incidence and association between ARDS and clinical outcomes in patients with different forms of acute brain injury requiring IMV in the intensive care unit (ICU). Methods: This was a preplanned secondary analysis of a prospective, multicenter, international cohort study (NCT03400904). We included brain-injured patients receiving IMV for ≥ 24 h. ARDS was the main exposure of interest and was identified during index ICU admission using the Berlin definition. We examined the incidence and adjusted association of ARDS with ICU mortality, ICU length of stay, duration of IMV, and extubation failure. Outcomes were evaluated using mixed-effect logistic regression and cause-specific Cox proportional hazards models. Results: 1492 patients from 67 hospitals and 16 countries were included in the analysis, of whom 137 individuals developed ARDS (9.2% of overall cohort). Across countries, the median ARDS incidence was 5.1% (interquartile range [IQR] 0-10; range 0-27.3). ARDS was associated with increased ICU mortality (adjusted odds ratio (OR) 2.66; 95% confidence interval [CI], 1.29-5.48), longer ICU length of stay (adjusted hazard ratio [HR] 0.59; 95% CI, 0.48-0.73), and longer duration of IMV (adjusted HR 0.54; 95% CI, 0.44-0.67). The association between ARDS and extubation failure approached statistical significance (adjusted HR 1.48; 95% CI 0.99-2.21). Higher ARDS severity was associated with incrementally longer ICU length of stay and longer cumulative duration of IMV. Findings remained robust in a sensitivity analysis evaluating the magnitude of unmeasured confounding. Conclusions: In this cohort of acutely brain-injured patients, the incidence of ARDS was similar to that reported in other mixed cohorts of critically ill patients. Development of ARDS was associated with worse outcomes.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert D. Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Bastien Perrot
- UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes Université, Tours Université, Nantes, France
| | - Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Raphael Cinotti
- UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes Université, Tours Université, Nantes, France
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel-Dieu, Nantes, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel-Dieu, Nantes, France
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Fawley JA, Tignanelli CJ, Werner NL, Kasotakis G, Mandell SP, Glass NE, Dries DJ, Costantini TW, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia. J Trauma Acute Care Surg 2023; 95:592-602. [PMID: 37314843 PMCID: PMC10545067 DOI: 10.1097/ta.0000000000004046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023]
Abstract
LEVEL OF EVIDENCE Therapeutic/Care Management: Level V.
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Taran S, Hamad DM, von Düring S, Malhotra AK, Veroniki AA, McCredie VA, Singh JM, Hansen B, Englesakis M, Adhikari NKJ. Factors associated with acute respiratory distress syndrome in brain-injured patients: A systematic review and meta-analysis. J Crit Care 2023; 77:154341. [PMID: 37235919 DOI: 10.1016/j.jcrc.2023.154341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is common in patients with acute brain injury admitted to the ICU. We aimed to identify factors associated with ARDS in this population. METHODS We searched MEDLINE, Embase, Cochrane Central, Scopus, and Web of Science from inception to January 14, 2022. Three reviewers independently screened articles and selected English-language studies reporting risk factors for ARDS in brain-injured adult patients. Data were extracted on ARDS incidence, adjusted and unadjusted risk factors, and clinical outcomes. Risk of bias was reported using the Quality in Prognostic Studies tool. Certainty of evidence was assessed using GRADE. RESULTS We selected 23 studies involving 6,961,284 patients with acute brain injury. The pooled cumulative incidence of ARDS after brain injury was 17.0% (95%CI 10.7-25.8). In adjusted analysis, factors associated with ARDS included sepsis (odds ratio (OR) 4.38, 95%CI 2.37-8.10; high certainty), history of hypertension (OR 3.11, 95%CI 2.31-4.19; high certainty), pneumonia (OR 2.69, 95%CI 2.35-3.10; high certainty), acute kidney injury (OR 1.44, 95%CI 1.30-1.59; moderate certainty), admission hypoxemia (OR 1.67, 95%CI 1.29-2.17; moderate certainty), male sex (OR 1.30, 95%CI 1.06-1.58; moderate certainty), and chronic obstructive pulmonary disease (OR 1.27, 95%CI 1.13-1.44; moderate certainty). Development of ARDS was independently associated with increased odds of in-hospital mortality (OR 3.12, 95% CI 1.39-7.00). CONCLUSIONS Multiple risk factors are associated with ARDS in brain-injured patients. These findings could be used to develop prognostic models for ARDS or as prognostic enrichment strategies for patient enrolment in future clinical trials.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Neurology, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
| | - Doulia M Hamad
- Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Stephan von Düring
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Intensive Care Division, Geneva University Hospitals (HUG) and Faculty of Medicine, University of Geneva, Switzerland
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Areti Angeliki Veroniki
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bettina Hansen
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Marina Englesakis
- Library and Health Information Services, University Health Network, Toronto, ON, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Li S, Li Y, Liu Y, Wu Y, Wang Q, Jin L, Zhang D. Therapeutic Peptides for Treatment of Lung Diseases: Infection, Fibrosis, and Cancer. Int J Mol Sci 2023; 24:ijms24108642. [PMID: 37239989 DOI: 10.3390/ijms24108642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Various lung diseases endanger people's health. Side effects and pharmaceutical resistance complicate the treatment of acute lung injury, pulmonary fibrosis, and lung cancer, necessitating the development of novel treatments. Antimicrobial peptides (AMPs) are considered to serve as a viable alternative to conventional antibiotics. These peptides exhibit a broad antibacterial activity spectrum as well as immunomodulatory properties. Previous studies have shown that therapeutic peptides including AMPs had remarkable impacts on animal and cell models of acute lung injury, pulmonary fibrosis, and lung cancer. The purpose of this paper is to outline the potential curative effects and mechanisms of peptides in the three types of lung diseases mentioned above, which may be used as a therapeutic strategy in the future.
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Affiliation(s)
- Shujiao Li
- School of Life Sciences, Liaoning University, Shenyang 110036, China
| | - Yuying Li
- School of Life Sciences, Liaoning University, Shenyang 110036, China
| | - Ying Liu
- Department of Stem Cells and Regenerative Medicine, Key Laboratory of Cell Biology, National Health Commission of China, and Key Laboratory of Medical Cell Biology, Ministry of Education of China, China Medical University, Shenyang 110122, China
| | - Yifan Wu
- Department of Stem Cells and Regenerative Medicine, Key Laboratory of Cell Biology, National Health Commission of China, and Key Laboratory of Medical Cell Biology, Ministry of Education of China, China Medical University, Shenyang 110122, China
| | - Qiuyu Wang
- School of Life Sciences, Liaoning University, Shenyang 110036, China
| | - Lili Jin
- School of Life Sciences, Liaoning University, Shenyang 110036, China
| | - Dianbao Zhang
- Department of Stem Cells and Regenerative Medicine, Key Laboratory of Cell Biology, National Health Commission of China, and Key Laboratory of Medical Cell Biology, Ministry of Education of China, China Medical University, Shenyang 110122, China
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Wahlster S, Sharma M, Taran S, Town JA, Stevens RD, Cinotti R, Asehoune K, Pelosi P, Robba C. Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial. Crit Care 2023; 27:156. [PMID: 37081474 PMCID: PMC10120226 DOI: 10.1186/s13054-023-04410-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/20/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. METHODS In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). RESULTS We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). CONCLUSIONS Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation.
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Affiliation(s)
- Sarah Wahlster
- Neurocritical Care, Department of Neurology, Harborview Medical Center, University of Washington, Box 359702, 325 9th Avenue, WA, 98104-2499, Seattle, USA.
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA.
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA.
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, USA
| | - Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, USA
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raphaël Cinotti
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France
| | - Karim Asehoune
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 10 Largo Rosanna Benzi, 16100, Genoa, Italy
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12
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Feldstein E, Ali S, Patel S, Raghavendran K, Martinez E, Blowes L, Ogulnick J, Bravo M, Dominguez J, Li B, Urhie O, Rosenberg J, Bowers C, Prabhakaran K, Bauershmidt A, Mayer SA, Gandhi CD, Al-Mufti F. Acute Respiratory Distress Syndrome in Patients with Subarachnoid Hemorrhage: Incidence, Predictive Factors, and Impact on Mortality. Interv Neuroradiol 2023; 29:189-195. [PMID: 35234070 PMCID: PMC10152822 DOI: 10.1177/15910199221082457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/04/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is a known predictor of poor outcomes in critically ill patients. We sought to examine the role ARDS plays in outcomes in subarachnoid hemorrhage (SAH) patients. Prior studies investigating the incidence of ARDS in SAH patients did not control for SAH severity. Hence, we sought to determine the incidence ARDS in patients diagnosed with aneurysmal SAH and investigate the predisposing risk factors and impact upon outcomes. METHODS A retrospective cohort study was conducted using the National Inpatient Sample (NIS) database for the years 2008 to 2014. Multivariate stepwise regression analysis was performed to identify the risk factors and outcome associated with developing ARDS in the setting of SAH. RESULTS We identified 170,869 patients with non-traumatic subarachnoid hemorrhage, of whom 6962 were diagnosed with ARDS and of those 4829 required mechanical ventilation. ARDS more frequently developed in high grade SAH patients (1.97 ± 0.05 vs. 1.15 ± 0.01; p < 0.0001). Neurologic predictors of ARDS included cerebral edema (OR 1.892, CI 1.180-3.034, p = 0.0035) and medical predictors included cardiac arrest (OR 4.642, CI 2.273-9.482, p < 0.0001) and cardiogenic shock (OR 2.984, CI 1.157-7.696, p = 0.0239). ARDS was associated with significantly worse outcomes (15.5% vs. 52.9% discharged home, 63.0% vs. 40.8% discharged to rehabilitation facility and 21.5% vs. 6.3% in-hospital mortality). CONCLUSION Patients with SAH who developed ARDS were less likely to be discharged home, more likely to need rehabilitation and had a significantly higher risk of mortality. The identification of risk factors contributing to ARDS is helpful for improving outcomes and resource utilization.
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Affiliation(s)
- Eric Feldstein
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Syed Ali
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Smit Patel
- UCLA Medical Center, Los Angeles, CA,
USA
| | | | - Erick Martinez
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Leah Blowes
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jonathan Ogulnick
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Michelle Bravo
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jose Dominguez
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Boyi Li
- University of North Carolina, Chapel
Hill, NC, USA
| | - Ogaga Urhie
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jon Rosenberg
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | | | | | - Stephan A. Mayer
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Chirag D. Gandhi
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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13
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Huffman EE, Dong BE, Clarke HA, Young LEA, Gentry MS, Allison DB, Sun RC, Waters CM, Alilain WJ. Cervical spinal cord injury leads to injury and altered metabolism in the lungs. Brain Commun 2023; 5:fcad091. [PMID: 37065091 PMCID: PMC10090796 DOI: 10.1093/braincomms/fcad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/17/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023] Open
Abstract
High-cervical spinal cord injury often disrupts respiratory motor pathways and disables breathing in the affected population. Moreover, cervically injured individuals are at risk for developing acute lung injury, which predicts substantial mortality rates. While the correlation between acute lung injury and spinal cord injury has been found in the clinical setting, the field lacks an animal model to interrogate the fundamental biology of this relationship. To begin to address this gap in knowledge, we performed an experimental cervical spinal cord injury (N = 18) alongside sham injury (N = 3) and naïve animals (N = 15) to assess lung injury in adult rats. We demonstrate that animals display some early signs of lung injury two weeks post-spinal cord injury. While no obvious histological signs of injury were observed, the spinal cord injured cohort displayed significant signs of metabolic dysregulation in multiple pathways that include amino acid metabolism, lipid metabolism, and N-linked glycosylation. Collectively, we establish for the first time a model of lung injury after spinal cord injury at an acute time point that can be used to monitor the progression of lung damage, as well as identify potential targets to ameliorate acute lung injury.
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Affiliation(s)
- Emily E Huffman
- Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY 40508, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky College of Medicine, Lexington, KY 40508, USA
| | - Brittany E Dong
- Department of Physiology, University of Kentucky College of Medicine, Lexington, KY 40508, USA
| | - Harrison A Clarke
- Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY 40508, USA
| | - Lyndsay E A Young
- Markey Cancer Center, University of Kentucky, Lexington, KY 40508, USA
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY 40508, USA
| | - Matthew S Gentry
- Markey Cancer Center, University of Kentucky, Lexington, KY 40508, USA
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY 40508, USA
| | - Derek B Allison
- Markey Cancer Center, University of Kentucky, Lexington, KY 40508, USA
- Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, KY 40508, USA
| | - Ramon C Sun
- Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY 40508, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky College of Medicine, Lexington, KY 40508, USA
| | - Christopher M Waters
- Department of Physiology, University of Kentucky College of Medicine, Lexington, KY 40508, USA
- Saha Cardiovascular Research Center, University of Kentucky College of Medicine, Lexington, KY 40508, USA
| | - Warren J Alilain
- Department of Neuroscience, University of Kentucky College of Medicine, Lexington, KY 40508, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky College of Medicine, Lexington, KY 40508, USA
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14
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Wu J, Gao W, Zhang H. Development of acute lung injury or acute respiratory distress syndrome after subarachnoid hemorrhage, predictive factors, and impact on prognosis. Acta Neurol Belg 2023:10.1007/s13760-023-02207-z. [PMID: 36922484 DOI: 10.1007/s13760-023-02207-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/30/2023] [Indexed: 03/17/2023]
Abstract
Acute lung injury or acute respiratory distress syndrome (ALI/ARDS) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH), and is associated with worse neurologic outcomes and longer hospitalization. However, the effect of ALI/ARDS in SAH has not been well elucidated. The purpose of this study was to determine the incidence of ALI/ARDS in a cohort of patients with SAH and to determine the risk factors for ALI/ARDS and their impact on patient prognosis. We performed a retrospective analysis of 167 consecutive patients with aSAH enrolled. ALI/ARDS patients were rigorously adjudicated using North American-European Consensus Conference definition. Regression analyses were used to test the risk factors for ALI/ARDS in patients with SAH. A total of 167 patients fulfilled the inclusion criteria, and 27% patients (45 of 167) developed ALI. Among all 45 ALI patients, 33 (20%, 33 of 167) patients met criteria for ARDS. On multivariate analysis, elderly patients, lower glasgow coma scale (GCS), higher Hunt-Hess grade, higher simplified acute physiology score (SAPS) II score, pre-existing pneumonia, gastric aspiration, hypoxemia, and tachypnea were the strongest risk factor for ALI/ARDS. Patients with ALI/ARDS showed worse clinical outcomes measured at 30 days. Development of ALI/ARDS was associated with a statistically significant increasing the odds of tracheostomy and hospital complications, and increasing duration of mechanical ventilation, intensive care unit (ICU) length and hospitalization stay. Development of ALI/ARDS is a severe complication of SAH and is associated with a poor clinical outcome, and further studies should focus on both prevention and management strategies specific to SAH-associated ALI/ARDS.
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Affiliation(s)
- Jiang Wu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215026, Jiangsu, People's Republic of China
| | - Wei Gao
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215026, Jiangsu, People's Republic of China
| | - Hongrong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215026, Jiangsu, People's Republic of China.
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15
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Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
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16
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The mechanical power in neurocritical care patients: is it useful? J Clin Monit Comput 2022; 36:1581-1583. [PMID: 35849210 DOI: 10.1007/s10877-022-00885-3] [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: 02/17/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
Patients with acute brain injury have been excluded in the majority of the randomized clinical trials which evaluated a lung protective strategy in patients with acute respiratory failure. It remains unclear if low tidal volume, higher PEEP levels and recruitment maneuvers by increasing both the intracranial and intrathoracic pressure and by leading to a permissible hypercapnia could furthermore deteriorate the acute brain injury and the final outcome. Mechanical power has been associated with the outcome in ARDS patients without brain injury. Jiang et al. demonstrated in neurocritical patients that non-survivors had a higher mechanical power compared to survivors. Mechanical power was associated with an increase in intensive care mortality risk and also to an enhanced risk of hospital mortality, prolonged intensive care length of stay and fewer ventilatory free days; in addition, the mechanical power could better predict mortality compared to the Glasgow Coma Scale.
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17
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Mechanical power of ventilation is associated with mortality in neurocritical patients: a cohort study. J Clin Monit Comput 2022; 36:1621-1628. [PMID: 35059914 PMCID: PMC9637601 DOI: 10.1007/s10877-022-00805-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
This study aimed to determine the predictive relevance of mechanical power in the clinical outcomes (such as ICU mortality, hospital mortality, 90-day mortality, length of ICU stay, and number of ventilator-free days at day 28) of neurocritical patients. This is a retrospective cohort analysis of an open-access clinical database known as MIMIC-III. The study included patients who had sustained an acute brain injury and required invasive ventilation for at least 24 h. Demographic parameters, disease severity scores (Glasgow coma scale), comorbidities, vital signs, laboratory parameters and ventilator parameters were collected within the first 24 h of ICU admission. The main outcome was the relationship between MP and ICU mortality. A total of 529 patients were selected for the study. The critical value of MP was 12.16 J/min, with the area under the curve (AUC) of the MP was 0.678 (95% CI 0.637-0.718), and compared to the GCS scores, the MP performed significantly better in discrimination (DeLong's test: p < 0.001). Among these patients elevated MP was associated to higher ICU mortality (OR 1.11; 95% CI 1.06-1.17; p < 0.001), enhanced the risk of hospital mortality, prolonged ICU stay, and decreased the number of ventilator-free days. In the subgroup analysis, high MP was associated with ICU mortality regardless of ARDS (OR 1.01, 95% CI 1.00-1.02, p = 0.009; OR 1.01, 95% CI 1.00-1.02, p = 0.018, respectively) or obesity (OR 1.01, 95% CI 1.00-1.02, p = 0.012; OR 1.01, 95% CI 1.01-1.02, p < 0.001, respectively). In neurocritical care patients undergoing invasive ventilation, elevated MP is linked to higher ICU mortality and a variety of other clinical outcomes.
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18
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Hatfield J, Ohnuma T, Soto AL, Komisarow JM, Vavilala MS, Laskowitz DT, James ML, Mathew JP, Hernandez AF, Goldstein BA, Treggiari M, Raghunathan K, Krishnamoorthy V. Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States. J Intensive Care Med 2022; 38:440-448. [PMID: 36445019 DOI: 10.1177/08850666221139223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: Describe contemporary ECMO utilization patterns among patients with traumatic brain injury (TBI) and examine clinical outcomes among TBI patients requiring ECMO. Design: Retrospective cohort study. Setting: Premier Healthcare Database (PHD) between January 2016 to June 2020. Subjects: Adult patients with TBI who were mechanically ventilated and stratified by exposure to ECMO. Results: Among patients exposed to ECMO, we examined the following clinical outcomes: hospital LOS, ICU LOS, duration of mechanical ventilation, and hospital mortality. Of our initial cohort (n = 59,612), 118 patients (0.2%) were placed on ECMO during hospitalization. Most patients were placed on ECMO within the first 2 days of admission (54.3%). Factors associated with ECMO utilization included younger age (OR 0.96, 95% CI (0.95–0.97)), higher injury severity score (ISS) (OR 1.03, 95% CI (1.01–1.04)), vasopressor utilization (2.92, 95% CI (1.90–4.48)), tranexamic acid utilization (OR 1.84, 95% CI (1.12–3.04)), baseline comorbidities (OR 1.06, 95% CI (1.03–1.09)), and care in a teaching hospital (OR 3.04, 95% CI 1.31–7.05). A moderate degree (ICC = 19.5%) of variation in ECMO use was explained at the individual hospital level. Patients exposed to ECMO had longer median (IQR) hospital and ICU length of stay (LOS) [26 days (11–36) versus 9 days (4–8) and 19.5 days (8–32) versus 5 days (2–11), respectively] and a longer median (IQR) duration of mechanical ventilation [18 days (8–31) versus 3 days (2–8)]. Patients exposed to ECMO experienced a hospital mortality rate of 33.9%, compared to 21.2% of TBI patients unexposed to ECMO. Conclusions: ECMO utilization in mechanically ventilated patients with TBI is rare, with significant variation across hospitals. The impact of ECMO on healthcare utilization and hospital mortality following TBI is comparable to non-TBI conditions requiring ECMO. Further research is necessary to better understand the role of ECMO following TBI and identify patients who may benefit from this therapy.
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Affiliation(s)
- Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, NC, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alexandria L. Soto
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Duke University School of Medicine, Durham, NC, USA
| | - Jordan M. Komisarow
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | | | | | | | - Miriam Treggiari
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Population Health Sciences, Duke University, Durham, NC, USA
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19
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Humayun M, Premraj L, Shah V, Cho SM. Mechanical ventilation in acute brain injury patients with acute respiratory distress syndrome. Front Med (Lausanne) 2022; 9:999885. [PMID: 36275802 PMCID: PMC9582443 DOI: 10.3389/fmed.2022.999885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/20/2022] [Indexed: 11/24/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is commonly seen in patients with acute brain injury (ABI), with prevalence being as high as 35%. These patients often have additional risk factors for ARDS compared to general critical care patients. Lung injury in ABI occurs secondary to catecholamine surge and neuro-inflammatory processes. ARDS patients benefit from lung protective ventilation using low tidal volumes, permissive hypercapnia, high PEEP, and lower PO2 goals. These strategies can often be detrimental in ABI given the risk of brain hypoxia and elevation of intracranial pressure (ICP). While lung protective ventilation is not contraindicated in ABI, special consideration is warranted to make sure it does not interfere with neurological recovery. Permissive hypercapnia with low lung volumes can be utilized in patients without any ICP issues but those with ICP elevations can benefit from continuous ICP monitoring to personalize PCO2 goals. Hypoxia leads to poor outcomes in ABI, hence the ARDSnet protocol of lower PO2 target (55–80 mmHg) might not be the best practice in patients with concomitant ARDS and ABI. High-normal PO2 levels are reasonable in target in severe ABI with ARDS. Studies have shown that PEEP up to 12 mmHg does not cause significant elevations in ICP and is safe to use in ABI though mean arterial pressure, respiratory system compliance, and cerebral perfusion pressure should be closely monitored. Given most trials investigating therapeutics in ARDS have excluded ABI patients, focused research is needed in the field to advance the care of these patients using evidence-based medicine.
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Affiliation(s)
- Mariyam Humayun
- Division of Neuroscience Critical Care, Department of Neurology, Neurosurgery, Surgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lavienraj Premraj
- School of Medicine, Griffith University, Gold Coast, QLD, Australia,Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Vishank Shah
- Division of Neuroscience Critical Care, Department of Neurology, Neurosurgery, Surgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Department of Neurology, Neurosurgery, Surgery, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States,*Correspondence: Sung-Min Cho
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20
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Cui Y, Xu L, Wang F, Wang Z, Tong X, Yan H. Orally Administered Brain Protein Combined With Probiotics Increases Treg Differentiation to Reduce Secondary Inflammatory Damage Following Craniocerebral Trauma. Front Immunol 2022; 13:928343. [PMID: 35874774 PMCID: PMC9298786 DOI: 10.3389/fimmu.2022.928343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/27/2022] [Indexed: 11/21/2022] Open
Abstract
Craniocerebral trauma is caused by external forces that can have detrimental effects on the vasculature and adjacent nerve cells at the site. After the mechanical and structural primary injury, a complex series of secondary cascades of injury exacerbates brain damage and cognitive dysfunction following mechanical and structural primary injury. Disruption of the blood-brain barrier and exposure of brain proteins following craniocerebral trauma, recognition by the immune system triggering autoimmune attack, and excessive secondary inflammatory responses causing malignant brain swelling, cerebral edema, and subsequent brain cell apoptosis provide a new direction for the suppression of brain inflammatory responses in the treatment of craniocerebral trauma. We observed that CD4+T/CD8+T in peripheral blood T cells of craniocerebral trauma rats were significantly higher than those of normal rats, and the ratio of CD4+CD25+Foxp3 (Foxp3)+Regulatory T cell (Treg) was significantly lower than that of normal rats and caused increased secondary inflammation. We constructed a rat model of post-surgical brain injury and orally administered brain protein combined with probiotics, which was observed to significantly reduce CD4+T/CD8+T and induce T-cell differentiation into CD4+CD25+Foxp3+Treg, thus, reducing secondary inflammatory responses following craniocerebral trauma. However, collecting intestinal stool and small intestinal tissues for broad target metabolomics, 16s rRNA bacteriomics, and the combined analysis of intestinal tissue proteomics revealed that oral administration of brain protein combined with probiotics activates glycerophospholipid and vitamin B6 metabolic pathways to promote the production of CD4+CD25+Foxp3+Treg. Therefore, we propose the novel idea that oral administration of brain protein combined with probiotics can induce immune tolerance by increasing Treg differentiation, thus, reducing secondary inflammatory injury following craniocerebral trauma.
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Affiliation(s)
- Yang Cui
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.,Department of Neurosurgery, Hebei Yanda Hospital, Langfang, China
| | - Lixia Xu
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China
| | - Fanchen Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Zhengang Wang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.,Department of Neurosurgery, Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xiaoguang Tong
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China.,Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hua Yan
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China.,Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
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22
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Association between Traumatic Subarachnoid Hemorrhage and Acute Respiratory Failure in Moderate-to-Severe Traumatic Brain Injury Patients. J Clin Med 2022; 11:jcm11143995. [PMID: 35887760 PMCID: PMC9318973 DOI: 10.3390/jcm11143995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 01/25/2023] Open
Abstract
Acute respiratory failure (ARF) with a high incidence among moderate-to-severe traumatic brain injury (M-STBI) patients plays a pivotal role in worsening neurological outcomes. Traumatic subarachnoid hemorrhage (tSAH) is highly prevalent in M-STBI, which is associated with significant adverse outcomes. In this retrospective cohort study, we aimed to explore the association between the severity of the tSAH and ARF in the M-STBI population. A total of 771 subjects were reviewed. Clinical and neuroimaging data of M-STBI patients were retrospectively collected, and ARF was ascertained retrospectively based on their electronic medical record. The degree of tSAH was classified according to Fisher’s criteria, and the grade of tSAH was dichotomized to a low Fisher grade (Fisher grade 1–2) and a high Fisher grade (Fisher grade 3–4). After exclusion procedures, the data of 695 M-STBI patients were analyzed. A total of 284 (30.8%) had a high Fisher grade on admission. The overall rate of ARF within 48 h upon admission was 34.4% (239/695); it was 29.5% (142/481) and 46.3% (99/214) for the low and high Fisher groups, respectively. In a full cohort, a high Fisher grade was associated with ARF after adjusting for age, gender, GCS, smoking history, comorbidities, multiple injuries, characteristics of TBI, and pulmonary factors (OR 1.78; 95% CI, 1.11–2.85, p = 0.016). This result remained robust in the comparisons after PSM (71/132, 42.8% vs. 53/132, 31.9%; OR, 1.59; 95% CI, 1.02–2.49, p = 0.042). A high Fisher SAH grade exposure on admission is associated with ARF in M-STBI patients.
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23
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Siwicka-Gieroba D, Terpilowska S, Robba C, Barud M, Kubik-Komar A, Dabrowski W. The Connection Between Selected Caspases Levels in Bronchoalveolar Lavage Fluid and Severity After Brain Injury. Front Neurol 2022; 13:796238. [PMID: 35665033 PMCID: PMC9161272 DOI: 10.3389/fneur.2022.796238] [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] [Received: 10/16/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The interaction between the brain and lungs has been the subject of many clinical reports, while the exact impact of brain injury on the physiology of the respiratory system is still subject to numerous experimental studies. The purpose of this study was to investigate the activation of selected caspases levels in bronchoalveolar lavage fluid (mini BALF) of patients after isolated brain injury and their correlation with the severity of the injury. Methods The analysis was performed on patients who were admitted to the intensive care unit (ICU) for severe isolated brain injury from March 2018 to April 2020. All patients were intubated and mechanically ventilated. Mini BALF was collected within the first 6–8 h after trauma and on days 3 and 7 after admission. The concentrations of selected caspases were determined and correlated with the severity of brain injury evaluated by the Rotterdam CT Score, Glasgow Coma Score, and 28-day mortality. Results Our results showed significantly elevated levels of selected caspases on days 3 and 7 after brain injury, and revealed apoptosis activation during the first 7 days after brain trauma. We found a significant different correlation between the elevation of selected caspases 3, 6, 8, and 9, and the Glasgow Coma Score, Rotterdam CT scale, and 28-day mortality. Conclusions The increased levels of selected caspases in the mini BALF in our patients indicate an intensified activation of apoptosis in the lungs, which is related to brain injury itself via various apoptotic pathways and correlates with the severity of brain injury.
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Affiliation(s)
- Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
- *Correspondence: Dorota Siwicka-Gieroba
| | | | - Chiara Robba
- Anaesthesia and Intensive Care, Policlinico San Martino, Deputy of the Neurointensive Care Section of European Society of Intensive Care Medicine, Genova, Italy
| | - Małgorzata Barud
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Agnieszka Kubik-Komar
- Department of Applied Mathematics and Computer Science, University of Life Sciences in Lublin, Lublin, Poland
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
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24
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Lim SH, Jung H, Youn DH, Kim TY, Han SW, Kim BJ, Lee JJ, Jeon JP. Mild Traumatic Brain Injury and Subsequent Acute Pulmonary Inflammatory Response. J Korean Neurosurg Soc 2022; 65:680-687. [PMID: 35574585 PMCID: PMC9452391 DOI: 10.3340/jkns.2021.0310] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/21/2022] [Indexed: 11/27/2022] Open
Abstract
Objective The influence of moderate-to-severe traumatic brain injury (TBI) on acute pulmonary injury is well established, but the association between acute pulmonary injury and mild TBI has not been well studied. Here, we evaluated the histological changes and fluctuations in inflammatory markers in the lungs to determine whether an acute pulmonary inflammatory response occurred after mild TBI.
Methods Mouse models of mild TBI (n=24) were induced via open-head injuries using a stereotaxic impactor. The brain and lungs were examined 6, 24, and 72 hours after injury and compared to sham-operated controls (n=24). Fluoro-Jade B staining and Astra blue and hematoxylin staining were performed to assess cerebral neuronal degeneration and pulmonary histological architecture. Quantitative real-time polymerase chain reaction analysis was done to measure inflammatory cytokines.
Results Increased neuronal degeneration and the mRNA expression of interleukin (IL)-6, tumor necrosis factor (TNF)-α, IL-10, and transforming growth factor (TGF)-β were observed after mild TBI. The IL-6, TNF-α, and TGF-β levels in mice with mild TBI were significantly different compared to those of sham-operated mice 24 hours after injury, and this was more pronounced at 72 hours. Mild TBI induced acute pulmonary interstitial edema with cell infiltration and alveolar morphological changes. In particular, a significant infiltration of mast cells was observed. Among the inflammatory cytokines, TNF-α was significantly increased in the lungs at 6 hours, but there was no significant difference 24 and 72 hours after injury.
Conclusion Mild TBI induced acute pulmonary interstitial inflammation and alveolar structural changes, which are likely to worsen the patient’s prognosis.
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Arjuna A, Mazzeo AT, Tonetti T, Walia R, Mascia L. Management of the Potential Lung Donor. Thorac Surg Clin 2022; 32:143-151. [PMID: 35512933 DOI: 10.1016/j.thorsurg.2021.11.005] [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: 11/30/2022]
Abstract
The use of donor management protocols has significantly improved recovery rates; however, the inherent instability of lungs after death results in low utilization rates of potential donor lungs. Donor lungs are susceptible to direct trauma, aspiration, neurogenic edema, ventilator-associated barotrauma, and ventilator-associated pneumonia. After irreversible brain injury and determination of futility of care, the goal of medical management of the donor shifts to maintaining hemodynamic stability and maximizing the likelihood of successful organ recovery.
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Affiliation(s)
- Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 West Thomas Road, Suite 500, Phoenix, AZ 85013, USA; Creighton University School of Medicine-Phoenix Campus, Phoenix, AZ, USA.
| | - Anna Teresa Mazzeo
- Department of Adult and Pediatric Pathology, University of Messina, Messina, Italy
| | - Tommaso Tonetti
- University of Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Medicine, Sant'Orsola Research Hospital - Bologna, Bologna, Italy. https://twitter.com/tomton87
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 West Thomas Road, Suite 500, Phoenix, AZ 85013, USA; Creighton University School of Medicine-Phoenix Campus, Phoenix, AZ, USA
| | - Luciana Mascia
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
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26
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Yang A, Liu B, Inoue T. Role of autonomic system imbalance in neurogenic pulmonary oedema. Eur J Neurosci 2022; 55:1645-1657. [PMID: 35277906 DOI: 10.1111/ejn.15648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/09/2022] [Accepted: 03/04/2022] [Indexed: 02/05/2023]
Abstract
Neurogenic pulmonary oedema (NPE) is a life-threatening complication that develops rapidly and dramatically after an injury to the central nervous system (CNS). The autonomic system imbalance produced by severe brain damage may play an important role in the development of NPE. Activation of the sympathetic nervous system and inhibition of the vagus nerve system are essential prerequisites for autonomic system imbalance. The more severe the damage, the more pronounced the phenomenon. Sympathetic hyperactivity is associated with increased release of catecholamines from peripheral sympathetic nerve endings, which can cause dramatic changes in haemodynamics and cause pulmonary oedema. On the other hand, the abnormal inflammatory response caused by vagus nerve inhibition may also play an important role in the pathogenesis of NPE. The perspective of autonomic system imbalance seems to perfectly integrate the existing pathogenesis of NPE and can explain the entire development progression of NPE.
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Affiliation(s)
- Aobing Yang
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
- Department of Physiology of Visceral Function and Body Fluid, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Bin Liu
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Tsuyoshi Inoue
- Department of Physiology of Visceral Function and Body Fluid, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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27
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Chacón-Aponte AA, Durán-Vargas ÉA, Arévalo-Carrillo JA, Lozada-Martínez ID, Bolaño-Romero MP, Moscote-Salazar LR, Grille P, Janjua T. Brain-lung interaction: a vicious cycle in traumatic brain injury. Acute Crit Care 2022; 37:35-44. [PMID: 35172526 PMCID: PMC8918716 DOI: 10.4266/acc.2021.01193] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
The brain-lung interaction can seriously affect patients with traumatic brain injury, triggering a vicious cycle that worsens patient prognosis. Although the mechanisms of the interaction are not fully elucidated, several hypotheses, notably the “blast injury” theory or “double hit” model, have been proposed and constitute the basis of its development and progression. The brain and lungs strongly interact via complex pathways from the brain to the lungs but also from the lungs to the brain. The main pulmonary disorders that occur after brain injuries are neurogenic pulmonary edema, acute respiratory distress syndrome, and ventilator-associated pneumonia, and the principal brain disorders after lung injuries include brain hypoxia and intracranial hypertension. All of these conditions are key considerations for management therapies after traumatic brain injury and need exceptional case-by-case monitoring to avoid neurological or pulmonary complications. This review aims to describe the history, pathophysiology, risk factors, characteristics, and complications of brain-lung and lung-brain interactions and the impact of different old and recent modalities of treatment in the context of traumatic brain injury.
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28
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Prevalence and Outcome of Acute Respiratory Distress Syndrome in Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Lung 2021; 199:603-610. [PMID: 34779897 PMCID: PMC8590970 DOI: 10.1007/s00408-021-00491-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/26/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) in patients with traumatic brain injury (TBI) is associated with increased mortality. Information on the prevalence of ARDS and its neurological outcome after TBI is sparse. We aimed to systematically review the prevalence, risk factors, and outcome of ARDS in TBI population. DATA SOURCES PubMed and four other databases (Embase, Cochrane Library, Web of Science Core Collection, and Scopus) from inception to July 6, 2020. STUDY SELECTION Randomized controlled trials (RCTs) and observational studies in patients older than 18 years old. DATA EXTRACTION Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for RCTs, the Newcastle-Ottawa Scale for cohort and case-control studies. Good neurological outcome was defined as Glasgow Outcome Scale ≥ 4. Random-effects meta-analyses were conducted to estimate pooled outcome prevalence and their 95% confidence intervals (CI). DATA SYNTHESIS We included 20 studies (n = 2830) with median age of 44 years (interquartile range [IQR] = 35-47, 64% male) and 79% (n = 2237) suffered severe TBI. In meta-analysis, 19% patients (95% CI = 0.13-0.27, I2 = 93%) had ARDS after TBI. The median time from TBI to ARDS was 3 days (IQR = 2-5). Overall survival at discharge for the TBI cohort was 70% (95% CI = 0.64-0.75; I2 = 85%) and good neurological outcome at any time was achieved in 31% of TBI patients (95% CI = 0.23-0.40; I2 = 88%). TBI cohort without ARDS had higher survival (67% vs. 57%, p = 0.01) and good neurological outcomes (34% vs. 23%, p = 0.02) compared to those with ARDS. We did not find any specific risk factors for developing ARDS. CONCLUSION In this meta-analysis, approximately one in five patients had ARDS shortly after TBI with the median time of 3 days. The presence of ARDS was associated with worse neurological outcome and mortality in TBI. Further research on prevention and intervention strategy of TBI-associated ARDS is warranted.
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29
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Proctor JL, Medina J, Rangghran P, Tamrakar P, Miller C, Puche A, Quan W, Coksaygan T, Drachenberg CB, Rosenthal RE, Stein DM, Kozar R, Wu F, Fiskum G. Air-Evacuation-Relevant Hypobaria Following Traumatic Brain Injury Plus Hemorrhagic Shock in Rats Increases Mortality and Injury to the Gut, Lungs, and Kidneys. Shock 2021; 56:793-802. [PMID: 33625116 DOI: 10.1097/shk.0000000000001761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Rats exposed to hypobaria equivalent to what occurs during aeromedical evacuation within a few days after isolated traumatic brain injury exhibit greater neurologic injury than those remaining at sea level. Moreover, administration of excessive supplemental O2 during hypobaria further exacerbates brain injury. This study tested the hypothesis that exposure of rats to hypobaria following controlled cortical impact (CCI)-induced brain injury plus mild hemorrhagic shock worsens multiple organ inflammation and associated mortality. In this study, at 24 h after CCI plus hemorrhagic shock, rats were exposed to either normobaria (sea level) or hypobaria (=8,000 ft altitude) for 6 h under normoxic or hyperoxic conditions. Injured rats exhibited mortality ranging from 30% for those maintained under normobaria and normoxia to 60% for those exposed to 6 h under hypobaric and hyperoxia. Lung histopathology and neutrophil infiltration at 2 days postinjury were exacerbated by hypobaria and hyperoxia. Gut and kidney inflammation at 30 days postinjury were also worsened by hypobaric hyperoxia. In conclusion, exposure of rats after brain injury and hemorrhagic shock to hypobaria or hyperoxia results in increased mortality. Based on gut, lung, and kidney histopathology at 2 to 30 days postinjury, increased mortality is consistent with multi-organ inflammation. These findings support epidemiological studies indicating that increasing aircraft cabin pressures to 4,000 ft altitude (compared with standard 8,000 ft) and limiting excessive oxygen administration will decrease critical complications during and following aeromedical transport.
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Affiliation(s)
- Julie L Proctor
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Juliana Medina
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Parisa Rangghran
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Pratistha Tamrakar
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Catriona Miller
- Department of Aeromedical Research, US Air Force School of Aerospace Medicine, Dayton, Ohio
| | | | - Wei Quan
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | - Robert E Rosenthal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
- Department of Emergency Medicine Program in Trauma, Section of Hyperbaric Medicine
| | - Deborah M Stein
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
- Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Rosemary Kozar
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Feng Wu
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
| | - Gary Fiskum
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Shock, Trauma, and Anesthesiology Research (STAR), University of Maryland School of Medicine, Baltimore, Maryland
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30
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Wu H, Gong L, Gu JC, Xing HW, Qian ZX, Mao Q. Proper Partial Pressure of Arterial Oxygen for Patients with Traumatic Brain Injury. Med Sci Monit 2021; 27:e932318. [PMID: 34663780 PMCID: PMC8540035 DOI: 10.12659/msm.932318] [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] [Indexed: 11/29/2022] Open
Abstract
Background The partial pressure of arterial oxygen (PaO2) is critical to the outcome of patients with traumatic brain injury (TBI). However, it is not clear what range of PaO2 should be maintained to improve patient outcome. The aim of this study was to explore the PaO2 value needed in the acute phase of TBI and provide new evidence for clinical practice. Material/Methods A total of 153 patients with TBI were enrolled retrospectively. Univariate and multivariate logistic regression analyses were conducted on sex, Glasgow Coma Scale (GCS) score on admission, PaO2 within 6 h of admission, oxygenation index, and other factors. The Glasgow Outcome Score (GOS) of the patient at discharge was used as an indicator of outcome. The good outcome group had GOS ≥4, and the poor outcome group had GOS <4. Results The 153 patients were divided into a good outcome group (n=62) and poor outcome group (n=91). There was a significant difference in sex, admission GCS, surgery, airway status, PaO2, and oxygen index within 6 h of admission between the 2 groups. Logistic regression analysis showed that PaO2 <60 mmHg, male sex, and admission GCS score of 3 to 12 were independent risk factors for a poor outcome. Conclusions Patients with TBI having PaO2 <60 mmHg within 6 h after admission were more likely to have poor outcomes. The upper limit value of PaO2 that affects the outcome of TBI in patients has not been found.
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Affiliation(s)
- Hong Wu
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Liang Gong
- Department of Neurosurgery, Punan Hospital, Shanghai, China (mainland)
| | - Jia-Cheng Gu
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
| | - Hong-Wei Xing
- Department of Neurosurgery, Linquan County People's Hospital, Fuyang, Anhui, China (mainland)
| | - Zhong-Xin Qian
- Department of Neurosurgery, Punan Hospital, Shanghai, China (mainland)
| | - Qing Mao
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (mainland)
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31
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Brain-Lung Conflicts and Patterns of Mechanical Ventilation. Crit Care Med 2021; 49:1200-1202. [PMID: 34135278 DOI: 10.1097/ccm.0000000000004957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Yeung E, Miller M, Wung C, Behm R, Cagir B, Granet P. Possible Predictive Factor of Acute Respiratory Distress Syndrome Development After Mild Traumatic Brain Injury: A Single Rural Trauma Center Preliminary Study. Cureus 2021; 13:e16508. [PMID: 34430122 PMCID: PMC8374992 DOI: 10.7759/cureus.16508] [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] [Accepted: 07/20/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Acute respiratory distress syndrome (ARDS) after mild traumatic brain injury (TBI) can be associated with significant morbidity and mortality. This study aimed to evaluate the potential predictive factors of ARDS development following mild TBI in trauma patients. Methods A retrospective chart review was done for adult trauma patients with mild TBI (GCS 13-15) requiring admission at our center from 2012 to 2020. Linear regression analysis and chi-square test were utilized to identify independent predictors of the association with ARDS in adults with mild TBI. Results A total of 784 mild TBI patients were admitted during the time of interest; 34 patients developed ARDS during their index hospitalization. Patients who had ARDS were more likely to have acute kidney injury (AKI; p < 0.0001), sepsis (p < 0.01), rib fractures (p < 0.05), use of anticoagulants (p < 0.001), deep vein thrombosis (p < 0.001), transfusion during the first 4four hours upon admission (p = 0.01), intravenous fluid (IVF) resuscitation during the first four hours (p <0.05), the first eight hours (p = 0.01), the first 12 hours (p = 0.03), and intubation upon the admission (p < 0.0001). ARDS associated with mild TBI demonstrated a statistically significant increase in mortality during the index hospitalization (p < 0.0001). Conclusion ARDS after mild TBI can be associated with significant morbidity and mortality. Key risk factors identified include AKI, sepsis, anticoagulant use, deep vein thrombosis (DVT), transfusion in the first four hours, IVF resuscitation in the first four, eight, and 12 hours, and intubation upon admission.
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Affiliation(s)
- Enoch Yeung
- Surgery, Guthrie Robert Packer Hospital, Sayre, USA
| | | | - Cynthia Wung
- Surgery, Guthrie Robert Packer Hospital, Sayre, USA
| | - Robert Behm
- Trauma/Critical Care, Guthrie Robert Packer Hospital, Sayre, USA
| | - Burt Cagir
- Colorectal Surgery, Guthrie Robert Packer Hospital, Sayre, USA
| | - Paul Granet
- Trauma/Surgical Critical Care, Guthrie Robert Packer Hospital, Sayre, USA
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Olanipekun T, Chris-Olaiya A, Esperti S, Nambudiri V, Duff R, Westney G. July Effect on Mortality and Complications in Patients With ARDS in US Teaching Hospitals. Am J Crit Care 2021; 30:e64-e70. [PMID: 34195773 DOI: 10.4037/ajcc2021608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Each July, teaching hospitals in the United States experience an influx of new resident and fellow physicians. It has been theorized that this occurrence may be associated with increased patient mortality, complication rates, and health care resource use, a phenomenon known as the "July effect." OBJECTIVE To assess the existence of a July effect in clinical outcomes of patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation in the intensive care unit in US teaching hospitals. METHODS The National Inpatient Sample database was queried for all adult patients with ARDS who received mechanical ventilation from 2012 to 2014. Using a multivariate difference-in-differences (DID) model, differences in mortality, ventilator-associated pneumonia, iatrogenic pneumothorax, central catheter-associated bloodstream infection, and Clostridium difficile infection were compared between teaching and nonteaching hospitals during April-May and July-August. RESULTS There were 70 535 and 43 175 hospitalizations meeting study criteria in teaching and nonteaching hospitals, respectively. Multivariate analyses revealed no differential effect on the rates of all-cause inpatient mortality (DID, 0.66; 95% CI, -0.42 to 1.75), C difficile infection (DID, 0.29; 95% CI, -0.19 to 0.78), central catheter-associated bloodstream infection (DID, 0.14; 95% CI, -0.04 to 0.33), iatrogenic pneumothorax (DID, 0.00; 95% CI, -0.25 to 0.24), ventilator-associated pneumonia (DID, 0.22; 95% CI, -0.05 to 0.49), and any complication (DID, 0.60; 95% CI, -0.01 to 1.20) for July-August versus April-May in teaching hospitals compared with nonteaching hospitals. CONCLUSION This study did not show a differential July effect on mortality outcomes and complication rates in ARDS patients receiving mechanical ventilation in teaching hospitals compared with nonteaching hospitals.
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Affiliation(s)
- Titilope Olanipekun
- Titilope Olanipekun is a resident physician, Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Abimbola Chris-Olaiya
- Abimbola Chris-Olaiya is chief medical resident, Department of Internal Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Shawn Esperti
- Shawn Esperti is a resident physician, Department of Internal Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Vinod Nambudiri
- Vinod Nambudiri is associate residency program director, Department of Internal Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Richard Duff
- Richard Duff is an intensivist, Department of Internal Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Gloria Westney
- Gloria Westney is an associate professor, Department of Internal Medicine, Morehouse School of Medicine, Atlanta, Georgia
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Sabet N, Soltani Z, Khaksari M. Multipotential and systemic effects of traumatic brain injury. J Neuroimmunol 2021; 357:577619. [PMID: 34058510 DOI: 10.1016/j.jneuroim.2021.577619] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of disability and mortality of people at all ages. Biochemical, cellular and physiological events that occur during primary injury lead to a delayed and long-term secondary damage that can last from hours to years. Secondary brain injury causes tissue damage in the central nervous system and a subsequent strong and rapid inflammatory response that may lead to persistent inflammation. However, this inflammatory response is not limited to the brain. Inflammatory mediators are transferred from damaged brain tissue to the bloodstream and produce a systemic inflammatory response in peripheral organs, including the cardiovascular, pulmonary, gastrointestinal, renal and endocrine systems. Complications of TBI are associated with its multiple and systemic effects that should be considered in the treatment of TBI patients. Therefore, in this review, an attempt was made to examine the systemic effects of TBI in detail. It is hoped that this review will identify the mechanisms of injury and complications of TBI, and open a window for promising treatment in TBI complications.
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Affiliation(s)
- Nazanin Sabet
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran; Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Soltani
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran; Department of Physiology and Pharmacology, Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammad Khaksari
- Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
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Gouvea Bogossian E, Peluso L, Creteur J, Taccone FS. Hyperventilation in Adult TBI Patients: How to Approach It? Front Neurol 2021; 11:580859. [PMID: 33584492 PMCID: PMC7875871 DOI: 10.3389/fneur.2020.580859] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 12/21/2020] [Indexed: 11/13/2022] Open
Abstract
Hyperventilation is a commonly used therapy to treat intracranial hypertension (ICTH) in traumatic brain injury patients (TBI). Hyperventilation promotes hypocapnia, which causes vasoconstriction in the cerebral arterioles and thus reduces cerebral blood flow and, to a lesser extent, cerebral blood volume effectively, decreasing temporarily intracranial pressure. However, hyperventilation can have serious systemic and cerebral deleterious effects, such as ventilator-induced lung injury or cerebral ischemia. The routine use of this therapy is therefore not recommended. Conversely, in specific conditions, such as refractory ICHT and imminent brain herniation, it can be an effective life-saving rescue therapy. The aim of this review is to describe the impact of hyperventilation on extra-cerebral organs and cerebral hemodynamics or metabolism, as well as to discuss the side effects and how to implement it to manage TBI patients.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Intensive Care Department, Erasmus Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Faden AI, Barrett JP, Stoica BA, Henry RJ. Bidirectional Brain-Systemic Interactions and Outcomes After TBI. Trends Neurosci 2021; 44:406-418. [PMID: 33495023 DOI: 10.1016/j.tins.2020.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/23/2020] [Accepted: 12/31/2020] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is a debilitating disorder associated with chronic progressive neurodegeneration and long-term neurological decline. Importantly, there is now substantial and increasing evidence that TBI can negatively impact systemic organs, including the pulmonary, gastrointestinal (GI), cardiovascular, renal, and immune system. Less well appreciated, until recently, is that such functional changes can affect both the response to subsequent insults or diseases, as well as contribute to chronic neurodegenerative processes and long-term neurological outcomes. In this review, we summarize evidence showing bidirectional interactions between the brain and systemic organs following TBI and critically assess potential underlying mechanisms.
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Affiliation(s)
- Alan I Faden
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - James P Barrett
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bogdan A Stoica
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rebecca J Henry
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Clark IA. Background to new treatments for COVID-19, including its chronicity, through altering elements of the cytokine storm. Rev Med Virol 2020; 31:1-13. [PMID: 33580566 PMCID: PMC7883210 DOI: 10.1002/rmv.2210] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 12/11/2022]
Abstract
Anti-tumour necrosis factor (TNF) biologicals, Dexamethasone and rIL-7 are of considerable interest in treating COVID-19 patients who are in danger of, or have become, seriously ill. Yet reducing sepsis mortality by lowering circulating levels of TNF lost favour when positive endpoints in earlier simplistic models could not be reproduced in well-conducted human trials. Newer information with anti-TNF biologicals has encouraged reintroducing this concept for treating COVID-19. Viral models have had encouraging outcomes, as have the effects of anti-TNF biologicals on community-acquired COVID-19 during their long-term use to treat chronic inflammatory states. The positive outcome of a large scale trial of dexamethasone, and its higher potency late in the disease, harmonises well with its capacity to enhance levels of IL-7Rα, the receptor for IL-7, a cytokine that enhances lymphocyte development and is increased during the cytokine storm. Lymphoid germinal centres required for antibody-based immunity can be harmed by TNF, and restored by reducing TNF. Thus the IL-7- enhancing activity of dexamethasone may explain its higher potency when lymphocytes are depleted later in the infection, while employing anti-TNF, for several reasons, is much more logical earlier in the infection. This implies dexamethasone could prove to be synergistic with rIL-7, currently being trialed as a COVID-19 therapeutic. The principles behind these COVID-19 therapies are consistent with the observed chronic hypoxia through reduced mitochondrial function, and also the increased severity of this disease in ApoE4-positive individuals. Many of the debilitating persistent aspects of this disease are predictably susceptible to treatment with perispinal etanercept, since they have cerebral origins.
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Affiliation(s)
- Ian A Clark
- Research School of Biology, Australian National University, Canberra, Australia
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Parker BM, Menaker J, Berry CD, Tesoreiero RB, O'Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg 2020; 87:949-953. [PMID: 33295187 DOI: 10.1177/0003134820956360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
METHODS We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate. RESULTS 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C. CONCLUSION VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.
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Affiliation(s)
- Brandon M Parker
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jay Menaker
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Cherisse D Berry
- Department of Surgery, School of Medicine, New York University, New York, NY, USA
| | | | - James V O'Connor
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Deborah M Stein
- Department of Surgery, Univeristy of California, San Francisco, CA, USA
| | - Thomas M Scalea
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
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Komisarow JM, Chen F, Vavilala MS, Laskowitz D, James ML, Krishnamoorthy V. Epidemiology and Outcomes of Acute Respiratory Distress Syndrome Following Isolated Severe Traumatic Brain Injury. J Intensive Care Med 2020; 37:68-74. [PMID: 33191844 DOI: 10.1177/0885066620972001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with traumatic brain injury (TBI) are at risk for extra-cranial complications, such as the acute respiratory distress syndrome (ARDS). We conducted an analysis of risk factors, mortality, and healthcare utilization associated with ARDS following isolated severe TBI. The National Trauma Data Bank (NTDB) dataset files from 2007-2014 were used to identify adult patients who suffered isolated [other body region-specific Abbreviated Injury Scale (AIS) < 3] severe TBI [admission total Glasgow Coma Scale (GCS) from 3 to 8 and head region-specific AIS >3]. In-hospital mortality was compared between patients who developed ARDS and those who did not. Utilization of healthcare resources (ICU length of stay, hospital length of stay, duration of mechanical ventilation, and frequency of tracheostomy and gastrostomy tube placement) was also examined. This retrospective cohort study included 38,213 patients with an overall ARDS occurrence of 7.5%. Younger age, admission tachycardia, pre-existing vascular and respiratory diseases, and pneumonia were associated with the development of ARDS. Compared to patients without ARDS, patients that developed ARDS experienced increased in-hospital mortality (OR 1.13, 95% CI 1.01-1.26), length of stay (p = <0.001), duration of mechanical ventilation (p = < 0.001), and placement of tracheostomy (OR 2.70, 95% CI 2.34-3.13) and gastrostomy (OR 2.42, 95% CI 2.06-2.84). After isolated severe TBI, ARDS is associated with increased mortality and healthcare utilization. Future studies should focus on both prevention and management strategies specific to TBI-associated ARDS.
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Affiliation(s)
| | - Fangyu Chen
- School of Medicine, 12277Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology, 7284University of Washington, Seattle, WA, USA
| | | | - Michael L James
- Department of Neurology, 12277Duke University, Durham, NC, USA.,Department of Anesthesiology, 12277Duke University, Durham, NC, USA
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Mrozek S, Gobin J, Constantin JM, Fourcade O, Geeraerts T. Crosstalk between brain, lung and heart in critical care. Anaesth Crit Care Pain Med 2020; 39:519-530. [PMID: 32659457 DOI: 10.1016/j.accpm.2020.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/05/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022]
Abstract
Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.
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Affiliation(s)
- Ségolène Mrozek
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France.
| | - Julie Gobin
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Jean-Michel Constantin
- Department of anaesthesia and critical care, Sorbonne university, La Pitié-Salpêtrière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Olivier Fourcade
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
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Reduction in Blood Glutamate Levels Combined With the Genetic Inactivation of A2AR Significantly Alleviate Traumatic Brain Injury-Induced Acute Lung Injury. Shock 2020; 51:502-510. [PMID: 29688987 DOI: 10.1097/shk.0000000000001170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Traumatic brain injury-induced acute lung injury (TBI-ALI) is a serious complication of traumatic brain injury (TBI). Our previous clinical study found that high levels of blood glutamate after TBI were closely related to the occurrence and severity of TBI-ALI, while it remains unknown whether a high concentration of blood glutamate directly causes or aggravates TBI-ALI. We found that inhibition of the adenosine A2A receptor (A2AR) after brain injury alleviated the TBI-ALI; however, it is unknown whether lowering blood glutamate levels in combination with inhibiting the A2AR would lead to better effects. Using mouse models of moderate and severe TBI, we found that intravenous administration of L-glutamate greatly increased the lung water content, lung-body index, level of inflammatory markers in bronchoalveolar lavage fluid and acute lung injury score and significantly decreased the PaO2/FiO2 ratio. Moreover, the incidence of TBI-ALI and the mortality rate were significantly increased, and the combined administration of A2AR activator and exogenous glutamate further exacerbated the above damaging effects. Conversely, lowering the blood glutamate level through peritoneal dialysis or intravenous administration of oxaloacetate notably improved the above parameters, and a further improvement was seen with concurrent A2AR genetic inactivation. These data suggest that A2AR activation aggravates the damaging effect of high blood glutamate concentrations on the lung and that combined treatment targeting both A2AR and blood glutamate may be an effective way to prevent and treat TBI-ALI.
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Pitoni S, D'Arrigo S, Grieco DL, Idone FA, Santantonio MT, Di Giannatale P, Ferrieri A, Natalini D, Eleuteri D, Jonson B, Antonelli M, Maggiore SM. Tidal Volume Lowering by Instrumental Dead Space Reduction in Brain-Injured ARDS Patients: Effects on Respiratory Mechanics, Gas Exchange, and Cerebral Hemodynamics. Neurocrit Care 2020; 34:21-30. [PMID: 32323146 PMCID: PMC7224122 DOI: 10.1007/s12028-020-00969-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Limiting tidal volume (VT), plateau pressure, and driving pressure is essential during the acute respiratory distress syndrome (ARDS), but may be challenging when brain injury coexists due to the risk of hypercapnia. Because lowering dead space enhances CO2 clearance, we conducted a study to determine whether and to what extent replacing heat and moisture exchangers (HME) with heated humidifiers (HH) facilitate safe VT lowering in brain-injured patients with ARDS. Methods Brain-injured patients (head trauma or spontaneous cerebral hemorrhage with Glasgow Coma Scale at admission < 9) with mild and moderate ARDS received three ventilatory strategies in a sequential order during continuous paralysis: (1) HME with VT to obtain a PaCO2 within 30–35 mmHg (HME1); (2) HH with VT titrated to obtain the same PaCO2 (HH); and (3) HME1 settings resumed (HME2). Arterial blood gases, static and quasi-static respiratory mechanics, alveolar recruitment by multiple pressure–volume curves, intracranial pressure, cerebral perfusion pressure, mean arterial pressure, and mean flow velocity in the middle cerebral artery by transcranial Doppler were recorded. Dead space was measured and partitioned by volumetric capnography. Results Eighteen brain-injured patients were studied: 7 (39%) had mild and 11 (61%) had moderate ARDS. At inclusion, median [interquartile range] PaO2/FiO2 was 173 [146–213] and median PEEP was 8 cmH2O [5–9]. HH allowed to reduce VT by 120 ml [95% CI: 98–144], VT/kg predicted body weight by 1.8 ml/kg [95% CI: 1.5–2.1], plateau pressure and driving pressure by 3.7 cmH2O [2.9–4.3], without affecting PaCO2, alveolar recruitment, and oxygenation. This was permitted by lower airway (− 84 ml [95% CI: − 79 to − 89]) and total dead space (− 86 ml [95% CI: − 73 to − 98]). Sixteen patients (89%) showed driving pressure equal or lower than 14 cmH2O while on HH, as compared to 7 (39%) and 8 (44%) during HME1 and HME2 (p < 0.001). No changes in mean arterial pressure, cerebral perfusion pressure, intracranial pressure, and middle cerebral artery mean flow velocity were documented during HH. Conclusion The dead space reduction provided by HH allows to safely reduce VT without modifying PaCO2 nor cerebral perfusion. This permits to provide a wider proportion of brain-injured ARDS patients with less injurious ventilation.
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Affiliation(s)
- Sara Pitoni
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Francesco Antonio Idone
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Maria Teresa Santantonio
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Pierluigi Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Alessandro Ferrieri
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Daniele Natalini
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Davide Eleuteri
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Bjorn Jonson
- Clinical Physiology, Skane University Hospital, 221 85, Lund, Sweden
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Maurizio Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy.
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Picetti E, Pelosi P, Taccone FS, Citerio G, Mancebo J, Robba C. VENTILatOry strategies in patients with severe traumatic brain injury: the VENTILO Survey of the European Society of Intensive Care Medicine (ESICM). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:158. [PMID: 32303255 PMCID: PMC7165367 DOI: 10.1186/s13054-020-02875-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/06/2020] [Indexed: 12/16/2022]
Abstract
Background Severe traumatic brain injury (TBI) patients often develop acute respiratory failure. Optimal ventilator strategies in this setting are not well established. We performed an international survey to investigate the practice in the ventilatory management of TBI patients with and without respiratory failure. Methods An electronic questionnaire, including 38 items and 3 different clinical scenarios [arterial partial pressure of oxygen (PaO2)/inspired fraction of oxygen (FiO2) > 300 (scenario 1), 150–300 (scenario 2), < 150 (scenario 3)], was available on the European Society of Intensive Care Medicine (ESICM) website between November 2018 and March 2019. The survey was endorsed by ESICM. Results There were 687 respondents [472 (69%) from Europe], mainly intensivists [328 (48%)] and anesthesiologists [206 (30%)]. A standard protocol for mechanical ventilation in TBI patients was utilized by 277 (40%) respondents and a specific weaning protocol by 198 (30%). The most common tidal volume (TV) applied was 6–8 ml/kg of predicted body weight (PBW) in scenarios 1–2 (72% PaO2/FIO2 > 300 and 61% PaO2/FiO2 150–300) and 4–6 ml/kg/PBW in scenario 3 (53% PaO2/FiO2 < 150). The most common level of highest positive end-expiratory pressure (PEEP) used was 15 cmH2O in patients with a PaO2/FiO2 ≤ 300 without intracranial hypertension (41% if PaO2/FiO2 150–300 and 50% if PaO2/FiO2 < 150) and 10 cmH2O in patients with intracranial hypertension (32% if PaO2/FiO2 150–300 and 33% if PaO2/FiO2 < 150). Regardless of the presence of intracranial hypertension, the most common carbon dioxide target remained 36–40 mmHg whereas the most common PaO2 target was 81–100 mmHg in all the 3 scenarios. The most frequent rescue strategies utilized in case of refractory respiratory failure despite conventional ventilator settings were neuromuscular blocking agents [406 (88%)], recruitment manoeuvres [319 (69%)] and prone position [292 (63%)]. Conclusions Ventilatory management, targets and practice of adult severe TBI patients with and without respiratory failure are widely different among centres. These findings may be helpful to define future investigations in this topic.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Via Gramsci 14, 43100, Parma, Italy.
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan - Bicocca, Monza, Italy
| | - Jordi Mancebo
- Department of Intensive Care, Sant Pau Hospital, Barcelona, Spain
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, Genoa, Italy
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Deng H, Yue JK, Winkler EA, Dhall SS, Manley GT, Tarapore PE. Pediatric firearm-related traumatic brain injury in United States trauma centers. J Neurosurg Pediatr 2019; 24:498-508. [PMID: 31491751 DOI: 10.3171/2019.5.peds19119] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric firearm injury is a leading cause of death and disability in the youth of the United States. The epidemiology of and outcomes following gunshot wounds to the head (GSWHs) are in need of systematic characterization. Here, the authors analyzed pediatric GSWHs from a population-based sample to identify predictors of prolonged hospitalization, morbidity, and death. METHODS All patients younger than 18 years of age and diagnosed with a GSWH in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB) in 2003-2012 were eligible for inclusion in this study. Variables of interest included injury intent, firearm type, site of incident, age, sex, race, health insurance, geographic region, trauma center level, isolated traumatic brain injury (TBI), hypotension in the emergency department, Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). Risk predictors for a prolonged hospital stay, morbidity, and mortality were identified. Odds ratios, mean increases or decreases (B), and 95% confidence intervals were reported. Statistical significance was assessed at α < 0.001 accounting for multiple comparisons. RESULTS In a weighted sample of 2847 pediatric patients with GSWHs, the mean age was 14.8 ± 3.3 years, 79.2% were male, and 59.0% had severe TBI (GCS score 3-8). The mechanism of assault (63.0%), the handgun as firearm (45.6%), and an injury incurred in a residential area (40.6%) were most common. The mean hospital length of stay was 11.6 ± 14.4 days for the survivors, for whom suicide injuries involved longer hospitalizations (B = 5.9-day increase, 95% CI 3.3-8.6, p < 0.001) relative to those for accidental injuries. Mortality was 45.1% overall but was greater with injury due to suicidal intent (mortality 71.5%, p < 0.001) or caused by a shotgun (mortality 56.5%, p < 0.001). Lower GCS scores, higher ISSs, and emergency room hypotension predicted poorer outcomes. Patients with private insurance had lower mortality odds than those with Medicare/Medicaid (OR 2.4, 95% CI 1.7-3.4, p < 0.001) or government insurance (OR 3.6, 95% CI 2.2-5.8, p < 0.001). Management at level II centers, compared to level I, was associated with lower odds of returning home (OR 0.3, 95% CI 0.2-0.5, p < 0.001). CONCLUSIONS From 2003 to 2012, with regard to pediatric TBI hospitalizations due to GSWHs, their proportion remained stable, those caused by accidental injuries decreased, and those attributable to suicide increased. Overall mortality was 45%. Hypotension, cranial and overall injury severity, and suicidal intent were associated with poor prognoses. Patients treated at level II trauma centers had lower odds of being discharged home. Given the spectrum of risk factors that predispose children to GSWHs, emphasis on screening, parental education, and standardization of critical care management is needed to improve outcomes.
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Affiliation(s)
- Hansen Deng
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 2Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco; and
| | - John K Yue
- 2Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco; and
- 3Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- 2Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco; and
- 3Department of Neurological Surgery, University of California, San Francisco, California
| | - Sanjay S Dhall
- 2Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco; and
- 3Department of Neurological Surgery, University of California, San Francisco, California
| | - Geoffrey T Manley
- 2Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco; and
- 3Department of Neurological Surgery, University of California, San Francisco, California
| | - Phiroz E Tarapore
- 2Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco; and
- 3Department of Neurological Surgery, University of California, San Francisco, California
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Blood purification by nonselective hemoadsorption prevents death after traumatic brain injury and hemorrhagic shock in rats. J Trauma Acute Care Surg 2019; 85:1063-1071. [PMID: 30211852 DOI: 10.1097/ta.0000000000002069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients who sustain traumatic brain injury (TBI) and concomitant hemorrhagic shock (HS) are at high risk of high-magnitude inflammation which can lead to poor outcomes and death. Blood purification by hemoadsorption (HA) offers an alternative intervention to reduce inflammation after injury. We tested the hypothesis that HA would reduce mortality in a rat model of TBI and HS. METHODS Male Sprague Dawley rats were subjected to a combined injury of a controlled cortical impact to their brain and pressure-controlled HS. Animals were subsequently instrumented with an extracorporeal blood circuit that passed through a cartridge for sham or experimental treatment. In experimental animals, the treatment cartridge was filled with proprietary beads (Cytosorbents, Monmouth Junction, NJ) that removed circulating molecules between 5 kDa and 60 kDa. Sham rats had equivalent circulation but no blood purification. Serial blood samples were analyzed with multiplex technology to quantify changes in a trauma-relevant panel of immunologic mediators. The primary outcome was survival to 96 hours postinjury. RESULTS Hemoadsorption improved survival from 47% in sham-treated rats to 86% in HA-treated rats. There were no treatment-related changes in histologic appearance. Hemoadsorption affected biomarker concentrations both during the treatment and over the ensuing 4 days after injury. Distinct changes in biomarker concentrations were also measured in survivor and nonsurvivor rats from the entire cohort of rats indicating biomarker patterns associated with survival and death after injury. CONCLUSION Blood purification by nonselective HA is an effective intervention to prevent death in a combined TBI/HS rat model. Hemoadsorption changed circulating concentrations of multiple inmmunologically active mediators during the treatment time frame and after treatment. Hemoadsorption has been safely implemented in human patients with sepsis and may be a treatment option after injury.
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Pulmonary Consult: Management of Severe Hypoxia in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Adediran T, Drumheller BC, McCunn M, Stein DM, Albrecht JS. Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury. J Surg Res 2019; 243:427-433. [PMID: 31279269 DOI: 10.1016/j.jss.2019.05.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/23/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Older adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI. However, sex differences in in-hospital complications among older adults after TBI have not been studied. The objective of this study was to assess sex differences in in-hospital complications after TBI among adults aged 65 y and older. METHODS We conducted a retrospective cohort study of adults aged ≥65 y treated for isolated moderate to severe TBI at the R Adams Cowley Shock Trauma Center between 1996 and 2012. Using the Shock Trauma Center registry, we identified TBI using the International Classification of Disease, Ninth Revision, Clinical Modification codes and required an abbreviated injury scale head score ≥3, abbreviated injury scale scores for other body regions ≤2, and a blunt injury mechanism. We searched the Shock Trauma Center registry for the International Classification of Disease, Ninth Revision, Clinical Modification codes representing in-hospital complications. RESULTS Of 2511 patients meeting inclusion criteria, 1283 (51.1%) were men and 635 (25.1%) developed an in-hospital complication. Men were more likely than women to develop an in-hospital complication (28.1% versus 22.0, P < 0.001). In an adjusted analysis, men were at increased risk of any in-hospital complication (hazards ratio 1.23; 95% confidence interval 1.05, 1.44) compared with women. CONCLUSIONS Older men were more likely to have any in-hospital complications than women.
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Affiliation(s)
- Timileyin Adediran
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Byron C Drumheller
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Maureen McCunn
- Department of Anesthesiology, Divisions of Trauma Anesthesiology and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah M Stein
- Program in Trauma, Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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de Roulet A, Burke RV, Lim J, Papillon S, Bliss DW, Ford HR, Upperman JS, Inaba K, Jensen AR. Pediatric trauma-associated acute respiratory distress syndrome: Incidence, risk factors, and outcomes. J Pediatr Surg 2019; 54:1405-1410. [PMID: 30041860 DOI: 10.1016/j.jpedsurg.2018.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/28/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND/PURPOSE Acute Respiratory Distress Syndrome (ARDS) results in significant morbidity and mortality in pediatric trauma victims. The objective of this study was to determine risk factors and outcomes specifically related to pediatric trauma-associated ARDS (PT-ARDS). METHODS A retrospective cohort (2007-2014) of children ≤18 years old from the American College of Surgeons National Trauma Data Bank (NTDB) was used to analyze incidence, risk factors, and outcomes related to PT-ARDS. RESULTS PT-ARDS was identified in 0.5% (2660/488,381) of the analysis cohort, with an associated mortality of 18.6% (494/2660). Mortality in patients with PT-ARDS most commonly occurred in the first week after injury. Risk factors associated with the development of PTARDS included nonaccidental trauma, near drowning, severe injury (AIS ≥ 3) to the head or chest, pneumonia, sepsis, thoracotomy, laparotomy, transfusion, and total parenteral nutrition use. After adjustment for age, injury complexity, injury mechanism, and physiologic variables, PT-ARDS was found to be independently associated with higher mortality (adjusted OR 1.33, 95% CI 1.18-1.51, p < 0.001). CONCLUSIONS PT-ARDS is a rare complication in pediatric trauma patients, but is associated with substantial mortality within 7 days of injury. Recognition and initiation of lung-protective measures early in the postinjury course may represent the best opportunity to change outcomes. LEVEL OF EVIDENCE Level 3 - Epidemiologic.
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Affiliation(s)
- Amory de Roulet
- Keck School of Medicine of the University of Southern California; Division of General Surgery, New York-Presbyterian Queens, Flushing, NY 11355.
| | - Rita V Burke
- Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Joanna Lim
- Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | | | - David W Bliss
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Henri R Ford
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Jeffrey S Upperman
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
| | - Kenji Inaba
- Keck School of Medicine of the University of Southern California; Division of Acute Care Surgery and Surgical Critical Care, LAC+USC Medical Center Los Angeles, CA 90027.
| | - Aaron R Jensen
- Keck School of Medicine of the University of Southern California; Division of Pediatric Surgery, Children's Hospital Los Angeles.
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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50
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Ventilatory Strategies in the Brain-injured Patient. Int Anesthesiol Clin 2019; 56:131-146. [PMID: 29227316 DOI: 10.1097/aia.0000000000000169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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