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Kawakita K, Shishido H, Kuroda Y. Review of Temperature Management in Traumatic Brain Injuries. J Clin Med 2024; 13:2144. [PMID: 38610909 PMCID: PMC11012999 DOI: 10.3390/jcm13072144] [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: 02/29/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024] Open
Abstract
Therapeutic hypothermia (TH) for severe traumatic brain injury has seen restricted application due to the outcomes of randomized controlled trials (RCTs) conducted since 2000. In contrast with earlier RCTs, recent trials have implemented active normothermia management in control groups, ensuring comparable intensities of non-temperature-related therapeutic interventions, such as neurointensive care. This change in approach may be a contributing factor to the inability to establish the efficacy of TH. Currently, an active temperature management method using temperature control devices is termed "targeted temperature management (TTM)". One of the goals of TTM for severe traumatic brain injury is the regulation of increased intracranial pressure, employing TTM as a methodology for intracranial pressure management. Additionally, fever in traumatic brain injury has been acknowledged as contributing to poor prognosis, underscoring the importance of proactively preventing fever. TTM is also employed for the preemptive prevention of fever in severe traumatic brain injury. As an integral component of current neurointensive care, it is crucial to precisely delineate the targets of TTM and to potentially apply them in the treatment of severe traumatic brain injury.
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Affiliation(s)
- Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Miki 760-0793, Japan;
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Yogo N, Abe T, Kano K, Muto Y, Kiyonaga S, Hirai K. Post-extubation dysphagia in pediatric trauma patients: a single-center case-series study. Sci Rep 2024; 14:3475. [PMID: 38347152 PMCID: PMC10861439 DOI: 10.1038/s41598-024-54247-x] [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: 10/12/2023] [Accepted: 02/10/2024] [Indexed: 02/15/2024] Open
Abstract
We aimed to investigate whether ventilator support time influences the occurrence of dysphagia in pediatric trauma patients. This case-series study was conducted in a single pediatric emergency and critical care center from April 2012 to March 2022. Trauma patients aged < 16 years who underwent tracheal intubation were divided into two groups based on the occurrence of dysphagia within 72 h after extubation, and their data were analyzed. Tracheal intubation was performed in 75 pediatric trauma patients, and 53 of them were included in the analysis. A total of 22 patients had post-extubation dysphagia and head trauma. The dysphagia group tended to have more severe head injuries (Abbreviated Injury Scale (AIS) 4 [4-5] vs. 4 [0-4]; p < 0.05), a longer ventilator support time (7 days [4-11] vs. 1 day [1-2.5]; p < 0.05), and a longer length of hospital stay (27 days [18.0-40.3] vs. 11 days [10.0-21.0]; p < 0.05). Severe head trauma and a long duration of tracheal intubation may be risk factors for dysphagia in pediatric trauma patients. Therefore, early recognition of these risk factors could assist in treatment planning for speech-language pathologist intervention and nutritional routes of administration.
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Affiliation(s)
- Naoki Yogo
- Department of Pediatric Emergency and Critical Care Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Ngamineminami Higashi-ku, Kumamoto, 861-8520, Japan.
| | - Takeru Abe
- Department of Quality and Safety in Healthcare, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa, 232-0024, Japan
| | - Kyoko Kano
- Department of Pediatric Emergency and Critical Care Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Ngamineminami Higashi-ku, Kumamoto, 861-8520, Japan
| | - Yuichiro Muto
- Department of Pediatric Emergency and Critical Care Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Ngamineminami Higashi-ku, Kumamoto, 861-8520, Japan
| | - Sachi Kiyonaga
- Department of Rehabilitation, Japanese Red Cross Kumamoto Hospital, 2-1-1 Ngamineminami, Higashi-ku, Kumamoto, 861-8520, Japan
| | - Katsuki Hirai
- Department of Pediatric Emergency and Critical Care Medicine, Japanese Red Cross Kumamoto Hospital, 2-1-1 Ngamineminami Higashi-ku, Kumamoto, 861-8520, Japan
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Hossain I, Rostami E, Marklund N. The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies. Curr Opin Crit Care 2023; 29:650-658. [PMID: 37851061 PMCID: PMC10624411 DOI: 10.1097/mcc.0000000000001094] [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: 10/19/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours. RECENT FINDINGS Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials. SUMMARY Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
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Affiliation(s)
- Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala
- Department of Neuroscience, Karolinska institute, Stockholm
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
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Dolmans RG, Nahed BV, Robertson FC, Peul WC, Rosenthal ES, Broekman ML. Practice-Pattern Variation in Sedation of Neurotrauma Patients in the Intensive Care Unit: An International Survey. J Intensive Care Med 2023; 38:1143-1150. [PMID: 37415510 PMCID: PMC10616999 DOI: 10.1177/08850666231186563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Background: Analgo-sedation plays an important role during intensive care management of traumatic brain injury (TBI) patients, however, limited evidence is available to guide practice. We sought to quantify practice-pattern variation in neurotrauma sedation management, surveying an international sample of providers. Methods: An electronic survey consisting of 56 questions was distributed internationally to neurocritical care providers utilizing the Research Electronic Data Capture platform. Descriptive statistics were used to quantitatively describe and summarize the responses. Results: Ninety-five providers from 37 countries responded. 56.8% were attending physicians with primary medical training most commonly in intensive care medicine (68.4%) and anesthesiology (26.3%). Institutional sedation guidelines for TBI patients were available in 43.2%. Most common sedative agents for induction and maintenance, respectively, were propofol (87.5% and 88.4%), opioids (60.2% and 70.5%), and benzodiazepines (53.4% and 68.4%). Induction and maintenance sedatives, respectively, are mostly chosen according to provider preference (68.2% and 58.9%) rather than institutional guidelines (26.1% and 35.8%). Sedation duration for patients with intracranial hypertension ranged from 24 h to 14 days. Neurological wake-up testing (NWT) was routinely performed in 70.5%. The most common NWT frequency was every 24 h (47.8%), although 20.8% performed NWT at least every 2 h. Richmond Agitation and Sedation Scale targets varied from deep sedation (34.7%) to alert and calm (17.9%). Conclusions: Among critically ill TBI patients, sedation management follows provider preference rather than institutional sedation guidelines. Wide practice-pattern variation exists for the type, duration, and target of sedative management and NWT performance. Future comparative effectiveness research investigating these differences may help optimize sedation strategies to promote recovery.
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Affiliation(s)
- Rianne G.F. Dolmans
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian V. Nahed
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Faith C. Robertson
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wilco C. Peul
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Neurosurgery, Leiden, the Netherlands
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marike L.D. Broekman
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurosurgery, Haaglanden Medical Centre, The Hague, the Netherlands
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Inoue G, Ohtaki Y, Satoh K, Odanaka Y, Katoh A, Suzuki K, Tomita Y, Eiraku M, Kikuchi K, Harano K, Yagi M, Uchida N, Dohi K. Sedation Therapy in Intensive Care Units: Harnessing the Power of Antioxidants to Combat Oxidative Stress. Biomedicines 2023; 11:2129. [PMID: 37626626 PMCID: PMC10452444 DOI: 10.3390/biomedicines11082129] [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: 06/15/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
In critically ill patients requiring intensive care, increased oxidative stress plays an important role in pathogenesis. Sedatives are widely used for sedation in many of these patients. Some sedatives are known antioxidants. However, no studies have evaluated the direct scavenging activity of various sedative agents on different free radicals. This study aimed to determine whether common sedatives (propofol, thiopental, and dexmedetomidine (DEX)) have direct free radical scavenging activity against various free radicals using in vitro electron spin resonance. Superoxide, hydroxyl radical, singlet oxygen, and nitric oxide (NO) direct scavenging activities were measured. All sedatives scavenged different types of free radicals. DEX, a new sedative, also scavenged hydroxyl radicals. Thiopental scavenged all types of free radicals, including NO, whereas propofol did not scavenge superoxide radicals. In this retrospective analysis, we observed changes in oxidative antioxidant markers following the administration of thiopental in patients with severe head trauma. We identified the direct radical-scavenging activity of various sedatives used in clinical settings. Furthermore, we reported a representative case of traumatic brain injury wherein thiopental administration dramatically affected oxidative-stress-related biomarkers. This study suggests that, in the future, sedatives containing thiopental may be redeveloped as an antioxidant therapy through further clinical research.
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Affiliation(s)
- Gen Inoue
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Yuhei Ohtaki
- Department of Emergency Medicine, School of Medicine, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-8461, Japan
| | - Kazue Satoh
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Yuki Odanaka
- Center for Instrumental Analysis, School of Pharmacy, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Akihito Katoh
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Keisuke Suzuki
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Yoshitake Tomita
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Manabu Eiraku
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Kazuki Kikuchi
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Kouhei Harano
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Masaharu Yagi
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
| | - Naoki Uchida
- Clinical Research Institute for Clinical Pharmacology and Therapeutics, Showa University Karasuyama Hospital, 6-11-11 Kitakarasuyama, Setagaya-ku, Tokyo 157-8577, Japan
| | - Kenji Dohi
- Department of Emergency, Disaster and Critical Care Medicine, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan; (G.I.)
- Department of Emergency Medicine, School of Medicine, The Jikei University, 3-25-8 Nishishinbashi, Minato-ku, Tokyo 105-8461, Japan
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Datta S, Lin F, Jones LD, Pingle SC, Kesari S, Ashili S. Traumatic brain injury and immunological outcomes: the double-edged killer. Future Sci OA 2023; 9:FSO864. [PMID: 37228857 PMCID: PMC10203904 DOI: 10.2144/fsoa-2023-0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of mortality and morbidity worldwide resulting from falls, car accidents, sports, and blast injuries. TBI is characterized by severe, life-threatening consequences due to neuroinflammation in the brain. Contact and collision sports lead to higher disability and death rates among young adults. Unfortunately, no therapy or drug protocol currently addresses the complex pathophysiology of TBI, leading to the long-term chronic neuroinflammatory assaults. However, the immune response plays a crucial role in tissue-level injury repair. This review aims to provide a better understanding of TBI's immunobiology and management protocols from an immunopathological perspective. It further elaborates on the risk factors, disease outcomes, and preclinical studies to design precisely targeted interventions for enhancing TBI outcomes.
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Affiliation(s)
- Souvik Datta
- Rhenix Lifesciences, 237 Arsha Apartments, Kalyan Nagar, Hyderabad, TG 500038, India
| | - Feng Lin
- CureScience, 5820 Oberlin Drive #202, San Diego, CA 92121, USA
| | | | | | - Santosh Kesari
- Saint John's Cancer Institute, Santa Monica, CA 90404, USA
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Sudhakar SK. Are GABAergic drugs beneficial in providing neuroprotection after traumatic brain injuries? A comprehensive literature review of preclinical studies. Front Neurol 2023; 14:1109406. [PMID: 36816561 PMCID: PMC9931759 DOI: 10.3389/fneur.2023.1109406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023] Open
Abstract
Traumatic brain injuries (TBI) caused by physical impact to the brain can adversely impact the welfare and well-being of the affected individuals. One of the leading causes of mortality and dysfunction in the world, TBI is a major public health problem facing the human community. Drugs that target GABAergic neurotransmission are commonly used for sedation in clinical TBI yet their potential to cause neuroprotection is unclear. In this paper, I have performed a rigorous literature review of the neuroprotective effects of drugs that increase GABAergic currents based on the results reported in preclinical literature. The drugs covered in this review include the following: propofol, benzodiazepines, barbiturates, isoflurane, and other drugs that are agonists of GABAA receptors. A careful review of numerous preclinical studies reveals that these drugs fail to produce any neuroprotection after a primary impact to the brain. In numerous circumstances, they could be detrimental to neuroprotection by increasing the size of the contusional brain tissue and by severely interfering with behavioral and functional recovery. Therefore, anesthetic agents that work by enhancing the effect of neurotransmitter GABA should be administered with caution of TBI patients until a clear and concrete picture of their neuroprotective efficacy emerges in the clinical literature.
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Second- and Third-Tier Therapies for Severe Traumatic Brain Injury. J Clin Med 2022; 11:jcm11164790. [PMID: 36013029 PMCID: PMC9410180 DOI: 10.3390/jcm11164790] [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: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.
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