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Hagedorn A, Haberl H, Adamzik M, Wolf A, Unterberg M. [Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 2 - Secondary Treatment Strategies, Long-term Outcome, Neuroprognostics and Chronification]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:466-478. [PMID: 39074791 DOI: 10.1055/a-2332-1423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.
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Poblete RA, Pena J, Kuo G, Tarzi F, Nguyen PL, Cen SY, Yaceczko S, Louie SG, Lewis MR, Martin M, Amar AP, Sanossian N, Sung G, Lyden PD. Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes. Neurotrauma Rep 2024; 5:574-583. [PMID: 39036427 PMCID: PMC11257118 DOI: 10.1089/neur.2024.0005] [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: 07/23/2024] Open
Abstract
Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and proimmune properties; however, their use has not been rigorously studied in human TBI populations. A single-center, retrospective, descriptive observational study was conducted at the LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared with those who received standard, polymeric EN with regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.
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Affiliation(s)
- Roy A. Poblete
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jesus Pena
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Grace Kuo
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Fawaz Tarzi
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Peggy L. Nguyen
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Steven Y. Cen
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Department of Radiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Shelby Yaceczko
- UCLA Health, University of California, Los Angeles, California, USA
| | - Stan G. Louie
- Department of Clinical Pharmacy, University of Southern California School of Pharmacy, Los Angeles, California, USA
| | - Meghan R. Lewis
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Matthew Martin
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Arun P. Amar
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Nerses Sanossian
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Gene Sung
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Patrick D. Lyden
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, California, USA
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Sawant N, Watanabe A, Ueda H, Okano H, Morita M. Incomplete accumulation of perilesional reactive astrocytes exacerbates wound healing after closed-head injury by increasing inflammation and BBB disruption. Exp Neurol 2024; 374:114700. [PMID: 38272160 DOI: 10.1016/j.expneurol.2024.114700] [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: 10/15/2023] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 01/27/2024]
Abstract
Wound healing after closed-head injury is a significant medical issue. However, conventional models of focal traumatic brain injury, such as fluid percussion injury and controlled cortical impact, employ mechanical impacts on the exposed cerebral cortex after craniotomy. These animal models are inappropriate for studying gliosis, as craniotomy itself induces gliosis. To address this, we developed a closed-head injury model and named "photo injury", which employs intense light illumination through a thinned-skull cranial window. Our prior work demonstrated that the gliosis of focal cerebral lesion after the photo injury does not encompass artificial gliosis and comprises two distinct reactive astrocyte subpopulations. The reactive astrocytes accumulated in the perilesional recovery area actively proliferate and express Nestin, a neural stem cell marker, while those in distal regions do not exhibit these traits. The present study investigated the role of perilesional reactive astrocytes (PRAs) in wound healing using the ablation of reactive astrocytes by the conditional knockout of Stat3. The extensive and non-selective ablation of reactive astrocytes in Nestin-Cre:Stat3f/f mice resulted in an exacerbation of injury, marked by increased inflammation and BBB disruption. On the other hand, GFAP-CreERT2:Stat3f/f mice exhibited the partial and selective ablation of the PRAs, while their exacerbation of injury was at the same extent as in Nestin-Cre:Stat3f/f mice. The comparison of these two mouse strains indicates that the PRAs are an essential astrocyte component for wound healing after closed-head injury, and their anti-inflammatory and regenerative functions are significantly affected even by incomplete accumulation. In addition, the reporter gene expression in the PRAs by GFAP-CreERT2 indicated a substantial elimination of these cells and an absence of differentiation into other cell types, despite Nestin expression, after wound healing. Thus, the accumulation and subsequent elimination of PRA are proposed as promising diagnostic and therapeutic avenues to bolster wound healing after closed-head injury.
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Affiliation(s)
- Nitin Sawant
- Biomolecular Organization, Department of Biology, Kobe University, Kobe, Hyogo 657-8501, Japan
| | - Airi Watanabe
- Biomolecular Organization, Department of Biology, Kobe University, Kobe, Hyogo 657-8501, Japan
| | - Haruna Ueda
- Biomolecular Organization, Department of Biology, Kobe University, Kobe, Hyogo 657-8501, Japan
| | - Hideyuki Okano
- Department of Physiology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Mitsuhiro Morita
- Biomolecular Organization, Department of Biology, Kobe University, Kobe, Hyogo 657-8501, Japan; Application Division, Center of Optical Scattering Image Science, Kobe University, Kobe, Hyogo 657-8501, Japan.
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De Rosa S, Battaglini D, Llompart-Pou JA, Godoy DA. Ten good reasons to consider gastrointestinal function after acute brain injury. J Clin Monit Comput 2024; 38:355-362. [PMID: 37418061 DOI: 10.1007/s10877-023-01050-0] [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: 04/21/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023]
Abstract
The brain-gut axis represents a bidirectional communication linking brain function with the gastrointestinal (GI) system. This interaction comprises a top-down communication from the brain to the gut, and a bottom-up communication from the gut to the brain, including neural, endocrine, immune, and humoral signaling. Acute brain injury (ABI) can lead to systemic complications including GI dysfunction. Techniques for monitoring GI function are currently few, neglected, and many under investigation. The use of ultrasound could provide a measure of gastric emptying, bowel peristalsis, bowel diameter, bowel wall thickness and tissue perfusion. Despite novel biomarkers represent a limitation in clinical practice, intra-abdominal pressure (IAP) is easy-to-use and measurable at bedside. Increased IAP can be both cause and consequence of GI dysfunction, and it can influence cerebral perfusion pressure and intracranial pressure via physiological mechanisms. Here, we address ten good reasons to consider GI function in patients with ABI, highlighting the importance of its assessment in neurocritical care.
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Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, Trento, Italy
| | - Denise Battaglini
- UO Clinica Anestesiologica e Terapia Intensiva, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Battaglini D, De Rosa S, Godoy DA. Crosstalk Between the Nervous System and Systemic Organs in Acute Brain Injury. Neurocrit Care 2024; 40:337-348. [PMID: 37081275 DOI: 10.1007/s12028-023-01725-1] [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] [Received: 12/03/2022] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
Organ crosstalk is a complex biological communication between distal organs mediated via cellular, soluble, and neurohormonal actions, based on a two-way pathway. The communication between the central nervous system and peripheral organs involves nerves, endocrine, and immunity systems as well as the emotional and cognitive centers of the brain. Particularly, acute brain injury is complicated by neuroinflammation and neurodegeneration causing multiorgan inflammation, microbial dysbiosis, gastrointestinal dysfunction and dysmotility, liver dysfunction, acute kidney injury, and cardiac dysfunction. Organ crosstalk has become increasingly popular, although the information is still limited. The present narrative review provides an update on the crosstalk between the nervous system and systemic organs after acute brain injury. Future research might help to target this pathophysiological process, preventing the progression toward multiorgan dysfunction in critically ill patients with brain injury.
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Affiliation(s)
- Denise Battaglini
- Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences, University of Trento, Via S. Maria Maddalena 1, 38122, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy.
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Webb AJ, Avramovska S, Qualls S, Lo CK, Roberts RJ, Barra ME. Impact of an enteral nutrition holding guideline on daily nutrition goals in patients taking phenytoin. Nutr Clin Pract 2023; 38:1334-1342. [PMID: 37537901 DOI: 10.1002/ncp.11051] [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: 02/01/2023] [Revised: 06/26/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Concomitant administration of enteral nutrition (EN) and phenytoin decreases phenytoin absorption. Concerns over impaired nutrition, however, may prevent EN from being held surrounding phenytoin administration. This study aimed to evaluate whether EN holding guidelines impacted nutrition goal achievement in patients taking phenytoin. METHODS Adult patients administered enteral phenytoin for acute or chronic seizures while receiving EN during a neurocritical care admission 6 months before and after EN holding guideline implementation were eligible. Patients without phenytoin concentrations or a clinical registered dietitian assessment were excluded. The primary outcome was the percentage of nutrition daily goals attained before and after implementation. Secondary end points included the incidence of hypoglycemia, differences in measured phenytoin concentrations, and rates of therapeutic (10-20 mcg/ml) and high-therapeutic (15-20 mcg/ml) concentration attainment. Concentrations were adjusted for hypoalbuminemia using the Winter-Tozer equation. RESULTS Fifty-five patients representing 412 patient days and 1110 phenytoin administrations were included with 29 preimplementation and 26 postimplementation patients. Median percent attainment of daily EN goals was consistent preimplementation and postimplementation (86% vs 83%, P = 0.48). No significant change in rates of days with hypoglycemia was observed. Adjusted phenytoin concentrations were similar before and after implementation (14.1 vs 15.2 mcg/ml, P = 0.45), but the preimplementation cohort had a lower proportion of high-therapeutic concentrations (23% vs 36%, P = 0.018). CONCLUSION Holding EN for phenytoin did not impact attainment of daily nutrition goals and was not associated with increased rates of hypoglycemia. This is the first study to evaluate the effect of EN holding on nutrition goals in patients receiving phenytoin.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Simona Avramovska
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pharmacy, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Stephanie Qualls
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carmen Kaman Lo
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Poblete RA, Pena JE, Kuo G, Tarzi F, Nguyen PL, Cen SY, Yaceczko S, Louie SG, Lewis MR, Martin M, Amar AP, Sanossian N, Sung G, Lyden PD. Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes. RESEARCH SQUARE 2023:rs.3.rs-3548036. [PMID: 37986931 PMCID: PMC10659558 DOI: 10.21203/rs.3.rs-3548036/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and pro-immune properties; however, their use has not been rigorously studied in human TBI populations. Methods A single-center, retrospective, descriptive observational study was conducted at LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥ 2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared to those who received standard, polymeric EN in regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. Results A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. Conclusion This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.
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Affiliation(s)
- Roy A Poblete
- University of Southern California Keck School of Medicine
| | - Jesus E Pena
- University of Southern California Keck School of Medicine
| | - Grace Kuo
- University of Southern California Keck School of Medicine
| | - Fawaz Tarzi
- University of Southern California Keck School of Medicine
| | - Peggy L Nguyen
- University of Southern California Keck School of Medicine
| | - Steven Y Cen
- University of Southern California Keck School of Medicine
| | - Shelby Yaceczko
- University of California Los Angeles Health System: UCLA Health
| | - Stan G Louie
- University of Southern California School of Pharmacy
| | - Meghan R Lewis
- University of Southern California Keck School of Medicine
| | - Matthew Martin
- University of Southern California Keck School of Medicine
| | - Arun P Amar
- University of Southern California Keck School of Medicine
| | | | - Gene Sung
- University of Southern California Keck School of Medicine
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Poblete RA, Yaceczko S, Aliakbar R, Saini P, Hazany S, Breit H, Louie SG, Lyden PD, Partikian A. Optimization of Nutrition after Brain Injury: Mechanistic and Therapeutic Considerations. Biomedicines 2023; 11:2551. [PMID: 37760993 PMCID: PMC10526443 DOI: 10.3390/biomedicines11092551] [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: 08/05/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Emerging science continues to establish the detrimental effects of malnutrition in acute neurological diseases such as traumatic brain injury, stroke, status epilepticus and anoxic brain injury. The primary pathological pathways responsible for secondary brain injury include neuroinflammation, catabolism, immune suppression and metabolic failure, and these are exacerbated by malnutrition. Given this, there is growing interest in novel nutritional interventions to promote neurological recovery after acute brain injury. In this review, we will describe how malnutrition impacts the biomolecular mechanisms of secondary brain injury in acute neurological disorders, and how nutritional status can be optimized in both pediatric and adult populations. We will further highlight emerging therapeutic approaches, including specialized diets that aim to resolve neuroinflammation, immunodeficiency and metabolic crisis, by providing pre-clinical and clinical evidence that their use promotes neurologic recovery. Using nutrition as a targeted treatment is appealing for several reasons that will be discussed. Given the high mortality and both short- and long-term morbidity associated with acute brain injuries, novel translational and clinical approaches are needed.
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Affiliation(s)
- Roy A. Poblete
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Shelby Yaceczko
- UCLA Health, University of California, 100 Medical Plaza, Suite 345, Los Angeles, CA 90024, USA;
| | - Raya Aliakbar
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Pravesh Saini
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Saman Hazany
- Department of Radiology, Keck School of Medicine, The University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA;
| | - Hannah Breit
- Department of Neurology, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA; (R.A.); (P.S.); (H.B.)
| | - Stan G. Louie
- Department of Clinical Pharmacy, School of Pharmacy, The University of Southern California, 1985 Zonal Avenue, Los Angeles, CA 90089, USA;
| | - Patrick D. Lyden
- Department of Neurology, Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute, Keck School of Medicine, The University of Southern California, 1540 Alcazar Street, Suite 215, Los Angeles, CA 90033, USA;
| | - Arthur Partikian
- Department of Neurology, Department of Pediatrics, Keck School of Medicine, The University of Southern California, 2010 Zonal Avenue, Building B, 3P61, Los Angeles, CA 90033, USA;
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Jeong H, Kim JH, Choo YH, Kim M, Lee S, Ha EJ, Oh J. Nutrition Therapy for Patients With Traumatic Brain Injury: A Narrative Review. Korean J Neurotrauma 2023; 19:177-184. [PMID: 37431366 PMCID: PMC10329886 DOI: 10.13004/kjnt.2023.19.e31] [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: 06/02/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023] Open
Abstract
Traumatic brain injury (TBI) is a global health and socio-economic problem, resulting in significant disability and mortality. Malnutrition is common in TBI patients and is associated with increased vulnerability to infection, higher morbidity and mortality rates, as well as longer stays in the intensive care unit and hospital. Following TBI, various pathophysiological mechanisms, such as hypermetabolism and hypercatabolism, affect patient outcomes. It is crucial to provide adequate nutrition therapy to prevent secondary brain damage and promote optimal recovery. This review includes a literature review and discusses the challenges encountered in clinical practice regarding nutrition in TBI patients. The focus is on determining energy requirements, timing and methods of nutrition delivery, promoting enteral tolerance, providing enteral nutrition to patients receiving vasopressors, and implementing trophic enteral nutrition. Enhancing our understanding of the current evidence regarding appropriate nutrition practices will contribute to improving overall outcomes for TBI patients.
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Affiliation(s)
- Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Jandari S, Rezvani R, Yousefian S, Mosalmanzadeh N, Bagherniya M, Soleimani D, Mousavian SZ, Shivappa N, Hébert JR, Jafarzadeh Esfahani A, Akhgari A, Jarahi L, Safarian M. The effect of low dietary inflammatory index score formula on inflammatory, metabolic, and clinical outcomes in critically ill traumatic brain injury patients: A single-blind randomized controlled pilot study. Food Sci Nutr 2023; 11:3365-3375. [PMID: 37324871 PMCID: PMC10261799 DOI: 10.1002/fsn3.3326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/20/2023] [Accepted: 03/10/2023] [Indexed: 06/17/2023] Open
Abstract
In traumatic brain injury (TBI) patients, a complex cascade of inflammatory responses are frequently observed following trauma. Numerous dietary agents have long been found to have potential in modulating inflammatory responses. This pilot study, designed an enteral formula with low inflammatory properties based on the dietary inflammatory index (DII®) and evaluated its effect on inflammatory and metabolic factors in critically ill TBI patients. This single-blind randomized controlled pilot study was conducted at the Neurosurgical ICU of Shahid Kamyab Hospital (Mashhad, Iran). A total of 20 TBI patients were randomly assigned to receive either low-DII score or standard formula at the intensive care unit (ICU). The primary outcomes of the study included clinical status, inflammatory biomarkers, APACHE II, SAPS II, SOFA, and NUTRIC scores. The trial groups did not differ significantly in baseline values. Following 14 days of intervention, there was a statistically significant decrease in the APACHE II, SAPS II, and NUTRIC scores and a significant increase in the GCS score in the low-DII score formula group compared to the standard formula group. Over 2 weeks, high sensitivity C-reactive protein (hs-CRP) values of -2.73 (95% CI: -3.67, -1.79) mg/dL in the low-DII score formula group versus 0.65 (95% CI: -0.29, 1.58) mg/dL in controls were obtained. Moreover, the length of hospital stay was longer for the standard formula group than for the low-DII score formula group. The low-DII score formula improves inflammatory factors (serum hs-CRP) and metabolic biomarkers (LDL-c and FBS). Furthermore, clinical outcomes, including the length of hospital stay and disease severity, appear to be enhanced.
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Affiliation(s)
- Sajedeh Jandari
- Department of Nutrition, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Reza Rezvani
- Department of Nutrition, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Sajedeh Yousefian
- Department of Nutrition SciencesVarastegan Institute for Medical SciencesMashhadIran
| | - Negin Mosalmanzadeh
- Department of Nutrition SciencesVarastegan Institute for Medical SciencesMashhadIran
| | - Mohammad Bagherniya
- Department of Community Nutrition, School of Nutrition and Food ScienceIsfahan University of Medical SciencesIsfahanIran
| | - Davood Soleimani
- Department of Nutritional Sciences, School of Nutritional SciencesKermanshah University of Medical SciencesKermanshahIran
| | - Seyedeh Zeynab Mousavian
- Department of Nutritional Sciences, School of Nutritional SciencesKermanshah University of Medical SciencesKermanshahIran
| | - Nitin Shivappa
- Cancer Prevention and Control ProgramUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Department of Epidemiology and Biostatistics, Arnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Connecting Health Innovations LLCColumbiaSouth CarolinaUSA
| | - James R. Hébert
- Cancer Prevention and Control ProgramUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Department of Epidemiology and Biostatistics, Arnold School of Public HealthUniversity of South CarolinaColumbiaSouth CarolinaUSA
| | - Ali Jafarzadeh Esfahani
- Department of Nutrition, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Abass Akhgari
- Targeted Drug Delivery Research CenterPharmaceutical Technology Institute, Mashhad University of Medical SciencesMashhadIran
- Department of Pharmaceutics, School of PharmacyMashhad University of Medical SciencesMashhadIran
| | - Lida Jarahi
- Department of Nutrition, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Mohammad Safarian
- Department of Nutrition, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
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11
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De Vlieger G, Meyfroidt G. Kidney Dysfunction After Traumatic Brain Injury: Pathophysiology and General Management. Neurocrit Care 2023; 38:504-516. [PMID: 36324003 PMCID: PMC9629888 DOI: 10.1007/s12028-022-01630-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) remains a major cause of mortality and morbidity, and almost half of these patients are admitted to the intensive care unit. Of those, 10% develop acute kidney injury (AKI) and 2% even need kidney replacement therapy (KRT). Although clinical trials in patients with TBI who have AKI are lacking, some general principles in this population may apply. The present review is an overview on the epidemiology and pathophysiology of AKI in patients with TBI admitted to the intensive care unit who are at risk for or who have developed AKI. A cornerstone in severe TBI management is preventing secondary brain damage, in which reducing the intracranial pressure (ICP) and optimizing the cerebral perfusion pressure (CPP) remain important therapeutic targets. To treat episodes of elevated ICP, osmolar agents such as mannitol and hypertonic saline are frequently administered. Although we are currently awaiting the results of a prospective randomized controlled trial that compares both agents, it is important to realize that both agents have been associated with an increased risk of developing AKI which is probably higher for mannitol compared with hypertonic saline. For the brain, as well as for the kidney, targeting an adequate perfusion pressure is important. Hemodynamic management based on the combined use of intravascular fluids and vasopressors is ideally guided by hemodynamic monitoring. Hypotonic albumin or crystalloid resuscitation solutions may increase the risk of brain edema, and saline-based solutions are frequently used but have a risk of hyperchloremia, which might jeopardize kidney function. In patients at risk, frequent assessment of serum chloride might be advised. Maintenance of an adequate CPP involves the optimization of circulating blood volume, often combined with vasopressor agents. Whether individualized CPP targets based on cerebrovascular autoregulation monitoring are beneficial need to be further investigated. Interestingly, such individualized perfusion targets are also under investigation in patients as a strategy to mitigate the risk for AKI in patients with chronic hypertension. In the small proportion of patients with TBI who need KRT, continuous techniques are advised based on pathophysiology and expert opinion. The need for KRT is associated with a higher risk of intracranial hypertension, especially if osmolar clearance occurs fast, which can even occur in continuous techniques. Precise ICP and CPP monitoring is mandatory, especially at the initiation of KRT.
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Affiliation(s)
- Greet De Vlieger
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
- Clinical Division of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
| | - Geert Meyfroidt
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Clinical Division of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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12
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Elliott E, Shoykhet M, Bell MJ, Wai K. Nutritional Support for Pediatric Severe Traumatic Brain Injury. Front Pediatr 2022; 10:904654. [PMID: 35656382 PMCID: PMC9152222 DOI: 10.3389/fped.2022.904654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
In critically ill children with severe traumatic brain injury (sTBI), nutrition may help facilitate optimal recovery. There is ongoing research regarding nutritional practices in the pediatric intensive care unit (PICU). These are focused on identifying a patient's most appropriate energy goal, the mode and timing of nutrient delivery that results in improved outcomes, as well as balancing these goals against inherent risks associated with nutrition therapy. Within the PICU population, children with sTBI experience complex physiologic derangements in the acute post-injury period that may alter metabolic demand, leading to nutritional needs that may differ from those in other critically ill patients. Currently, there are relatively few studies examining nutrition practices in PICU patients, and even fewer studies that focus on pediatric sTBI patients. Available data suggest that contemporary neurocritical care practices may largely blunt the expected hypermetabolic state after sTBI, and that early enteral nutrition may be associated with lower morbidity and mortality. In concordance with these data, the most recent guidelines for the management of pediatric sTBI released by the Brain Trauma Foundation recommend initiation of enteral nutrition within 72 h to improve outcome (Level 3 evidence). In this review, we will summarize available literature on nutrition therapy for children with sTBI and identify gaps for future research.
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Affiliation(s)
- Elizabeth Elliott
- Critical Care Medicine, Children's National Hospital, Washington, DC, United States
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13
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Kofler M, Beer R, Marinoni S, Schiefecker AJ, Gaasch M, Rass V, Lindner A, Lanosi BA, Rhomberg P, Pfausler B, Thomé C, Stover JF, Schmutzhard E, Helbok R. Early supplemental parenteral nutrition for the achievement of nutritional goals in subarachnoid hemorrhage patients: An observational cohort study. PLoS One 2022; 17:e0265729. [PMID: 35303046 PMCID: PMC8932621 DOI: 10.1371/journal.pone.0265729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 03/07/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Enteral nutrition (EN) often fails to achieve nutritional goals in neurocritical care patients. We sought to investigate the safety and utility of supplemental parenteral nutrition (PN) in subarachnoid hemorrhage (SAH) patients. Materials and methods Data of 70 consecutive patients with non-traumatic SAH admitted to the neurological intensive care unit of a tertiary referral center were prospectively collected and retrospectively analyzed. We targeted the provision of 20–25 kilocalories per kilogram bodyweight per day (kcal/kg/d) by enteral nutrition. Supplemental PN was given when this target could not be reached. Nutritional data were analyzed for up to 14 days of ICU stay. Hospital complications were tested for associations with impaired enteral feeding. The amounts of EN and PN were tested for associations with the level of protein delivery and functional outcome. Repeated measurements within subjects were handled utilizing generalized estimating equations. Results Forty (27 women and 13 men) of 70 screened patients were eligible for the analysis. Median age was 61 (IQR 49–71) years, 8 patients (20%) died in the hospital. Thirty-six patients (90%) received PN for a median duration of 8 (IQR 4–12) days. The provision of 20 kcal/kg by EN on at least 1 day of ICU stay was only achieved in 24 patients (60%). Hydrocephalus (p = 0.020), pneumonia (p = 0.037) and sepsis (p = 0.013) were associated with impaired enteral feeding. Neither the amount nor the duration of PN administration was associated with an increased risk of severe complications or poor outcome. Supplemental PN was associated with significantly increased protein delivery (p<0.001). In patients with sepsis or pneumonia, there was an association between higher protein delivery and good functional outcome (p<0.001 and p = 0.031), but not in the overall cohort (p = 0.08). Conclusions Enteral feeding was insufficient to achieve nutritional goals in subarachnoid hemorrhage patients. Supplemental PN was safe and associated with increased protein delivery. A higher protein supply was associated with good functional outcome in patients who developed sepsis or pneumonia.
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Affiliation(s)
- Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Stephanie Marinoni
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J. Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bogdan A. Lanosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Medical Informatics, UMIT–University for Health Sciences, Hall, Austria
| | - Paul Rhomberg
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - John F. Stover
- Fresenius Kabi Germany, Bad Homburg vor der Höhe, Germany
| | - Erich Schmutzhard
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- * E-mail:
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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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16
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Marini CP, McNelis J, Petrone P. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Lim SW, Su HC, Nyam TTE, Chio CC, Kuo JR, Wang CC. Ceftriaxone therapy attenuates brain trauma in rats by affecting glutamate transporters and neuroinflammation and not by its antibacterial effects. BMC Neurosci 2021; 22:54. [PMID: 34521349 PMCID: PMC8439027 DOI: 10.1186/s12868-021-00659-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ceftriaxone is a β-lactam antibiotic used to treat central nervous system infections. Whether the neuroprotective effects of ceftriaxone after TBI are mediated by attenuating neuroinflammation but not its antibacterial actions is not well established. METHODS Anesthetized male Sprague-Dawley rats were divided into sham-operated, TBI + vehicle, and TBI + ceftriaxone groups. Ceftriaxone was intraperitoneally injected at 0, 24, and 48 h with 50 or 250 mg/kg/day after TBI. During the first 120 min after TBI, we continuously measured heart rate, arterial pressure, intracranial pressure (ICP), and cerebral perfusion pressure. The infarct volume was measured by TTC staining. Motor function was measured using the inclined plane. Glutamate transporter 1 (GLT-1), neuronal apoptosis and TNF-α expression in the perilesioned cortex were investigated using an immunofluorescence assay. Bacterial evaluation was performed by Brown and Brenn's Gram staining. These parameters above were measured at 72 h after TBI. RESULTS Compared with the TBI + vehicle group, the TBI + ceftriaxone 250 mg/kg group showed significantly lower ICP, improved motor dysfunction, reduced body weight loss, decreased infarct volume and neuronal apoptosis, decreased TBI-induced microglial activation and TNF-α expression in microglia, and increased GLT-1 expression in neurons and microglia. However, the grades of histopathological changes of antibacterial effects are zero. CONCLUSIONS The intraperitoneal injection of ceftriaxone with 250 mg/kg/day for three days may attenuate TBI by increasing GLT-1 expression and reducing neuroinflammation and neuronal apoptosis, thereby resulting in an improvement in functional outcomes, and this neuroprotective effect is not related to its antibacterial effects.
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Affiliation(s)
- Sher-Wei Lim
- Department of Neurosurgery, Chi-Mei Medical Center, Chiali, Tainan, Taiwan
- Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Hui-Chen Su
- Departments of Pharmacy, Chi-Mei Medical Center, Tainan, Taiwan
| | - Tee-Tau Eric Nyam
- Departments of Neurosurgery, Chi-Mei Medical Center, 901 Chung Hwa Road, Yung Kang City, Tainan, Taiwan
| | - Chung-Ching Chio
- Departments of Neurosurgery, Chi-Mei Medical Center, 901 Chung Hwa Road, Yung Kang City, Tainan, Taiwan
| | - Jinn-Rung Kuo
- Departments of Neurosurgery, Chi-Mei Medical Center, 901 Chung Hwa Road, Yung Kang City, Tainan, Taiwan
- Departments of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Che-Chuan Wang
- Departments of Neurosurgery, Chi-Mei Medical Center, 901 Chung Hwa Road, Yung Kang City, Tainan, Taiwan
- Departments of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
- Center for General Education, Southern Taiwan University of Science and Technology, Tainan, Taiwan
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Acosta JA, Fernández Ortega JF, Pérez Quesada S. Recommendations for specialized nutritional-metabolic treatment of the critical patient: Neurocritical patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units. Med Intensiva 2021; 44 Suppl 1:69-72. [PMID: 32532415 DOI: 10.1016/j.medin.2020.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/21/2020] [Accepted: 01/25/2020] [Indexed: 11/26/2022]
Affiliation(s)
- J A Acosta
- Hospital General Universitario de Alicante, Alicante, España.
| | | | - S Pérez Quesada
- Hospital General Universitario de Alicante, Alicante, España
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19
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Suzumura R, Fujimoto A, Sato K, Baba S, Kubota S, Itoh S, Shibamoto I, Enoki H, Okanishi T. Nutritional Intervention Facilitates Food Intake after Epilepsy Surgery. Brain Sci 2021; 11:brainsci11040514. [PMID: 33920634 PMCID: PMC8073881 DOI: 10.3390/brainsci11040514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background: We investigated whether nutritional intervention affected food intake after epilepsy surgery and if intravenous infusions were required in patients with epilepsy. We hypothesized that postoperative food intake would be increased by nutritional intervention. The purpose of this study was to compare postoperative food intake in the periods before and after nutritional intervention. Methods: Between September 2015 and October 2020, 124 epilepsy surgeries were performed. Of these, 65 patients who underwent subdural electrode placement followed by open cranial epilepsy surgery were studied. Postoperative total food intake, rate of maintenance of food intake, and total intravenous infusion were compared in the periods before and after nutritional intervention. Results: A total of 26 females and 39 males (age range 3–60, mean 27.1, standard deviation (SD) 14.3, median 26 years) were enrolled. Of these, 18 females and 23 males (3–60, mean 28.2, SD 15.1, median 26 years) were in the pre-nutritional intervention period group, and eight females and 16 males (5–51, mean 25.2, SD 12.9, median 26.5 years) were in the post-nutritional intervention period group. The post-nutritional intervention period group showed significantly higher food intake (p = 0.015) and lower total infusion (p = 0.006) than the pre-nutritional intervention period group. Conclusion: The nutritional intervention increased food intake and also reduced the total amount of intravenous infusion. To identify the cut-off day to cease the intervention and to evaluate whether the intervention can reduce the complication rate, a multicenter study with a large number of patients is warranted.
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Affiliation(s)
- Rika Suzumura
- Department of Nutrition, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (R.S.); (S.K.); (S.I.)
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (K.S.); (S.B.); (H.E.); (T.O.)
- Seirei Christopher University, Shizuoka 433-8558, Japan;
- Correspondence: ; Tel.: +81-53-474-2222; Fax: +81-53-475-7596
| | - Keishiro Sato
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (K.S.); (S.B.); (H.E.); (T.O.)
- Seirei Christopher University, Shizuoka 433-8558, Japan;
| | - Shimpei Baba
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (K.S.); (S.B.); (H.E.); (T.O.)
| | - Satoko Kubota
- Department of Nutrition, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (R.S.); (S.K.); (S.I.)
| | - Sayuri Itoh
- Department of Nutrition, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (R.S.); (S.K.); (S.I.)
| | | | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (K.S.); (S.B.); (H.E.); (T.O.)
| | - Tohru Okanishi
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka 430-8558, Japan; (K.S.); (S.B.); (H.E.); (T.O.)
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20
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Swanson LC, Trujillo EA, Thiede GH, Katzenberger RJ, Shishkova E, Coon JJ, Ganetzky B, Wassarman DA. Survival Following Traumatic Brain Injury in Drosophila Is Increased by Heterozygosity for a Mutation of the NF-κB Innate Immune Response Transcription Factor Relish. Genetics 2020; 216:1117-1136. [PMID: 33109529 PMCID: PMC7768241 DOI: 10.1534/genetics.120.303776] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) pathologies are caused by primary and secondary injuries. Primary injuries result from physical damage to the brain, and secondary injuries arise from cellular responses to primary injuries. A characteristic cellular response is sustained activation of inflammatory pathways commonly mediated by nuclear factor-κB (NF-κB) transcription factors. Using a Drosophila melanogaster TBI model, we previously found that the main proximal transcriptional response to primary injuries is triggered by activation of Toll and Imd innate immune response pathways that engage NF-κB factors Dif and Relish (Rel), respectively. Here, we found by mass spectrometry that Rel protein level increased in fly heads at 4-8 hr after TBI. To investigate the necessity of Rel for secondary injuries, we generated a null allele, Reldel , by CRISPR/Cas9 editing. When heterozygous but not homozygous, the Reldel mutation reduced mortality at 24 hr after TBI and increased the lifespan of injured flies. Additionally, the effect of heterozygosity for Reldel on mortality was modulated by genetic background and diet. To identify genes that facilitate effects of Reldel on TBI outcomes, we compared genome-wide mRNA expression profiles of uninjured and injured +/+, +/Reldel , and Reldel /Reldel flies at 4 hr following TBI. Only a few genes changed expression more than twofold in +/Reldel flies relative to +/+ and Reldel /Reldel flies, and they were not canonical innate immune response genes. Therefore, Rel is necessary for TBI-induced secondary injuries but in complex ways involving Rel gene dose, genetic background, diet, and possibly small changes in expression of innate immune response genes.
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Affiliation(s)
- Laura C Swanson
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
- Medical Scientist Training Program, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
| | - Edna A Trujillo
- Department of Chemistry, College of Letters & Science, University of Wisconsin-Madison, Madison, Wisconsin 53706
- National Center for Quantitative Biology of Complex Systems, University of Wisconsin-Madison, Madison, Wisconsin 53706
| | - Gene H Thiede
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
| | - Rebeccah J Katzenberger
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
| | - Evgenia Shishkova
- National Center for Quantitative Biology of Complex Systems, University of Wisconsin-Madison, Madison, Wisconsin 53706
- Department of Biomolecular Chemistry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
| | - Joshua J Coon
- Department of Chemistry, College of Letters & Science, University of Wisconsin-Madison, Madison, Wisconsin 53706
- National Center for Quantitative Biology of Complex Systems, University of Wisconsin-Madison, Madison, Wisconsin 53706
- Department of Biomolecular Chemistry, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
- Morgridge Institute for Research, Madison, Wisconsin 53706
| | - Barry Ganetzky
- Department of Genetics, College of Agricultural and Life Sciences, University of Wisconsin-Madison, Madison, Wisconsin 53706
| | - David A Wassarman
- Department of Medical Genetics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53706
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Peng R, Li H, Yang L, Chen X, Zeng L, Bo Z, Zhang L. Immunonutrition for traumatic brain injury in children and adolescents: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e037014. [PMID: 32883725 PMCID: PMC7473625 DOI: 10.1136/bmjopen-2020-037014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the leading cause of paediatric trauma death and disability worldwide. The 'Guidelines for the Management of Severe Traumatic Brain Injury (Fourth Edition)' recommend that nutritional goals should be achieved within 5-7 days of injury. Immune-enhancing nutrition or immunonutrition, referring to the addition of specialised nutrients, including glutamine, alanine, omega-3 fatty acids and nucleotides, to standard nutrition formulas, may improve surgical outcomes in the perioperative period. However, the role of immune-enhancing nutritional supplements for patients with paediatric TBI remains unclear. We will conduct a systematic review to determine the efficacy and safety of immunonutrition for patients with paediatric TBI and provide evidence for clinical decision-making. METHODS AND ANALYSIS Studies reporting immune-enhancing nutrition treatments for patients with paediatric TBI will be included. Outcomes of interest include the length of hospital stay, wound infections, all-cause mortality, non-wound infection, including pneumonia, urinary tract infection and bacteraemia, and the reports adverse events. Duration of follow-up has no restriction. Primary studies consisting of randomised controlled trials (RCTs) and non-RCTs will be eligible for this review, and only studies published in English will be included. We will search the Medline, Embase and Cochrane Library databases from their inception dates to January 2020. We will also search clinicaltrials.gov and the WHO International Clinical Trials Registry Platform for additional information. Two reviewers will independently select studies and extract data. Risk-of-bias will be assessed with tools based on the Cochrane risk-of-bias criteria and Newcastle-Ottawa Quality Assessment Scale. A meta-analysis will be used to pool data when there are sufficient studies with homogeneity. Heterogeneity of the estimates across studies will be assessed; if necessary, a subgroup analysis will be performed to explore the source of heterogeneity. The Grades of Recommendation, Assessment, Development and Evaluation method will be applied to assess the level of evidence obtained from this systematic review. ETHICS AND DISSEMINATION The proposed systematic review and meta-analysis will be based on published data, and thus ethical approval is not required. The results of this review will be published. PROSPERO REGISTRATION NUMBER CRD42020154814.
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Affiliation(s)
- Rong Peng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
- Department of Clinical Nutrition, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hailong Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lijun Yang
- Department of General Practice Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Xinwei Chen
- Department of Critical Medicine, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Linan Zeng
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Zhenyan Bo
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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Correlation of brain flow variables and metabolic crisis: a prospective study in patients with severe traumatic brain injury. Eur J Trauma Emerg Surg 2020; 48:537-544. [DOI: 10.1007/s00068-020-01447-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
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Perović M, Jović M, Todorović S, Đorđević AM, Milanović D, Kanazir S, Lončarević-Vasiljković N. Neuroprotective effects of food restriction in a rat model of traumatic brain injury - the role of glucocorticoid signaling. Nutr Neurosci 2020; 25:537-549. [PMID: 32476608 DOI: 10.1080/1028415x.2020.1769410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is one of the most common causes of neurological damage in young and middle aged people. Food restriction (FR) has been shown to act neuroprotectively in animal models of stroke and TBI. Indeed, our previous studies showed that FR attenuates inflammation, through suppression of microglial activation and TNF-α production, suppresses caspase-3-induced neuronal cell death and enhances neuroplasticity in the rat model of TBI. Glucocorticoids (GCs) play a central role in mediating both molecular and behavioral responses to food restriction. However, the exact mechanisms of FR neuroprotection in TBI are still unclear. The goal of the present study was to examine whether FR exerts its beneficial effects by altering the glucocorticoid receptor (GR) signaling alone and/or together with other protective factors. METHODS To this end, we examined the effects of FR (50% of regular daily food intake for 3 months prior to TBI) on the protein levels of total GR, GR phosphoisoform Ser232 (p-GR) and its transcriptional activity, as well as 11β-HSD1, NFκB (p65) and HSP70 as factors related to the GR signaling. RESULTS Our results demonstrate that FR applied prior to TBI significantly changes p-GR levels, and it's transcriptional activity during the recovery period after TBI. Moreover, as a pretreatment, FR modulates other protective factors in response to TBI, such as 11β-HSD1, NF-κB (p65) and HSP70 that act in parallel with GR in it's anti-inflammatory and neuroprotective effects in the rat model of brain injury. CONCLUSION Our results suggest that prophylactic FR represents a potent non-invasive approach capable of changing GR signalling, together with other factors related to the GR signaling in the model of TBI.
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Affiliation(s)
- Milka Perović
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
| | - Milena Jović
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
| | - Smilja Todorović
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
| | - Aleksandra Mladenović Đorđević
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
| | - Desanka Milanović
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
| | - Selma Kanazir
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
| | - Nataša Lončarević-Vasiljković
- Department of Neurobiology, Institute for Biological Research 'Siniša Stanković' - National Institute of Republic of Serbia, University of Belgrade Belgrade, Serbia
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Arora N, Mehta TR. Role of the ketogenic diet in acute neurological diseases. Clin Neurol Neurosurg 2020; 192:105727. [DOI: 10.1016/j.clineuro.2020.105727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 12/31/2022]
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Kurtz P, Rocha EEM. Nutrition Therapy, Glucose Control, and Brain Metabolism in Traumatic Brain Injury: A Multimodal Monitoring Approach. Front Neurosci 2020; 14:190. [PMID: 32265626 PMCID: PMC7105880 DOI: 10.3389/fnins.2020.00190] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
The goal of neurocritical care in patients with traumatic brain injury (TBI) is to prevent secondary brain damage. Pathophysiological mechanisms lead to loss of body mass, negative nitrogen balance, dysglycemia, and cerebral metabolic dysfunction. All of these complications have been shown to impact outcomes. Therapeutic options are available that prevent or mitigate their negative impact. Nutrition therapy, glucose control, and multimodality monitoring with cerebral microdialysis (CMD) can be applied as an integrated approach to optimize systemic immune and organ function as well as adequate substrate delivery to the brain. CMD allows real-time bedside monitoring of aspects of brain energy metabolism, by measuring specific metabolites in the extracellular fluid of brain tissue. Sequential monitoring of brain glucose and lactate/pyruvate ratio may reveal pathologic processes that lead to imbalances in supply and demand. Early recognition of these patterns may help individualize cerebral perfusion targets and systemic glucose control following TBI. In this direction, recent consensus statements have provided guidelines and recommendations for CMD applications in neurocritical care. In this review, we summarize data from clinical research on patients with severe TBI focused on a multimodal approach to evaluate aspects of nutrition therapy, such as timing and route; aspects of systemic glucose management, such as intensive vs. moderate control; and finally, aspects of cerebral metabolism. Research and clinical applications of CMD to better understand the interplay between substrate supply, glycemic variations, insulin therapy, and their effects on the brain metabolic profile were also reviewed. Novel mechanistic hypotheses in the interpretation of brain biomarkers were also discussed. Finally, we offer an integrated approach that includes nutritional and brain metabolic monitoring to manage severe TBI patients.
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Affiliation(s)
- Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Eduardo E M Rocha
- Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
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Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Early enteral nutrition in patients with severe traumatic brain injury: a propensity score-matched analysis using a nationwide inpatient database in Japan. Am J Clin Nutr 2020; 111:378-384. [PMID: 31751450 DOI: 10.1093/ajcn/nqz290] [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] [Received: 06/17/2019] [Accepted: 10/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Whether enteral nutrition (EN) should be administered early in severe traumatic brain injury (TBI) patients has not been fully addressed. OBJECTIVE The present study aimed to evaluate whether early EN can reduce mortality or nosocomial pneumonia among severe TBI patients. METHODS Using the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2017 linked with the Survey for Medical Institutions, we identified patients admitted for intracranial injury with Japan Coma Scale scores ≥30 (corresponding to Glasgow Coma Scale scores ≤8) at admission. We designated patients who started EN within 2 d of admission as the early EN group, and those who started EN at 3-5 d after admission as the delayed EN group. The primary outcome was in-hospital mortality. The secondary outcome was nosocomial pneumonia. Propensity score-matched analyses were performed to compare the outcomes between the 2 groups. RESULTS We identified 3080 eligible patients during the 36-mo study period, comprising 1100 (36%) in the early EN group and 1980 (64%) in the delayed EN group. After propensity score matching, there was no significant difference in in-hospital mortality (difference: -0.3%; 95% CI: -3.7%, 3.1%) between the 2 groups. The proportion of nosocomial pneumonia was significantly lower in the early EN group than in the delayed EN group (difference: -3.2%; 95% CI: -5.9%, -0.4%). CONCLUSIONS Early EN may not reduce mortality, but may reduce nosocomial pneumonia in patients with severe TBI.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes. RECENT FINDINGS Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based. SUMMARY Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.
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Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant AA, Parks J, Byerly S, Lee EE, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. Advances in nutrition for the surgical patient. Curr Probl Surg 2019; 56:343-398. [DOI: 10.1067/j.cpsurg.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Preeti S, Kadam A, Kadam S, Vaidya U, Kumar P, Bhagat I, Pandit A, Chouthai NS. Anthropometric measures as biomarkers of neurodevelopmental outcomes of newborns with moderate to severe hypoxic ischemic encephalopathy. J Neonatal Perinatal Med 2019; 12:127-134. [PMID: 30741696 DOI: 10.3233/npm-17151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Perinatal asphyxia is a prominent cause of neonatal mortality in the developing world. Growth in head circumference is associated with improved neurodevelopment. Previous studies found a positive correlation between additional dietary supplementation and growth in head circumference among newborns with perinatal brain injury. This study aims to evaluate the association between anthropometric parameters and developmental outcomes in newborns with hypoxic ischemic encephalopathy (HIE). METHODS Newborns at ≥36 weeks gestation with moderate to severe HIE were included in the study and growth parameters were monitored. Newborns with life-threatening anomalies were excluded. None of the study participants received therapeutic hypothermia (TH). Developmental Assessment Scale for Indian Infants (DASII) was used to evaluate neurodevelopmental outcomes at 1 year of age. RESULTS Of 76 study participants, 46 were followed for 12 months, 28 died, and 2 were lost to follow-up. HIE stage III, Apgar score <5 at 5 minutes of age, pH ≤ 7.1 on first blood gas and base deficit > - 16 was associated with death or disability at 1 year of age. All anthropometric parameters were significantly lower in presence of death or disability. pH ≤ 7.1 at birth (odds ratio: 11.835, 95% CI 2.273-61.629, p = 0.003) and weight gain at one year (odds ratio 1.001, 95% CI 1.000-1.002, p = 0.03) were significantly associated with death and disability. CONCLUSION pH > 7.1 at birth, and weight gain were associated with better neurodevelopmental outcomes at 1 year of age. Thus, in addition to TH, nutritional interventions may potentially improve outcomes among newborns with HIE.
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Affiliation(s)
- S Preeti
- Department of Pediatrics, KEM Hospital, Pune, India
| | - A Kadam
- Department of Pediatrics, KEM Hospital, Pune, India
| | - S Kadam
- Department of Pediatrics, KEM Hospital, Pune, India
| | - U Vaidya
- Department of Pediatrics, KEM Hospital, Pune, India
| | - P Kumar
- Division of Neonatal-Perinatal Medicine, Wayne State University, Children's Hospital of Michigan and Hutzel Women's Hospital, Detroit, MI, USA
| | - I Bhagat
- Division of Neonatal-Perinatal Medicine, Wayne State University, Children's Hospital of Michigan and Hutzel Women's Hospital, Detroit, MI, USA
| | - A Pandit
- Department of Pediatrics, KEM Hospital, Pune, India
| | - N S Chouthai
- Division of Neonatal-Perinatal Medicine, Wayne State University, Children's Hospital of Michigan and Hutzel Women's Hospital, Detroit, MI, USA
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Enteral Nutrition Initiation in Children Admitted to Pediatric Intensive Care Units After Traumatic Brain Injury. Neurocrit Care 2019; 30:193-200. [PMID: 30171446 DOI: 10.1007/s12028-018-0597-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of death and long-term disability among injured children. Early feeding has been shown to improve outcomes in adults, with some similar evidence in children with severe TBI. We aimed to examine the current practice of initiation of enteral nutrition in children with TBI and to evaluate the risk factors associated with delayed initiation of enteral nutrition. METHODS This retrospective, multicenter study used the Pediatric Trauma Assessment and Management Database including all children with head trauma discharged from five pediatric intensive care units (PICU) at pediatric trauma centers between January 1, 2013 and December 31, 2013. We compared demographics, injury and procedure data, time to initiation of nutrition, and injury and illness severity scores between patients who received enteral nutrition early (≤ 48 h) and late (> 48 h). Fisher's exact and Mann-Whitney U tests compared discrete and continuous variables. Univariate and multivariable analyses evaluated variables associated with delayed initiation of feeding. Outcomes of interest included mortality, complications, ventilator days, hospital and ICU length of stay, and functional status at ICU discharge. RESULTS In the 416 patients in the study, the overall mortality was 2.6%. The majority of patients (83%; range 69-88% between five sites, p = 0.0008) received enteral nutrition within 48 h of PICU admission. Lower Glasgow Coma Scale scores and higher Injury Severity Score (ISS) were independently associated with delayed initiation of enteral nutrition. Delayed enteral nutrition was independently associated with worse functional status at PICU discharge (p = 0.02) but was not associated with mortality or increased length of stay. CONCLUSIONS Children with severe TBI and higher ISS were more likely to have delayed initiation of enteral nutrition. Delayed enteral nutrition was an independent risk factor for worse functional status at ICU discharge for the entire cohort, but not for the severe TBI group.
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Yu J, Zhu H, Taheri S, Monday WL, Perry S, Kindy MS. Reduced Neuroinflammation and Improved Functional Recovery after Traumatic Brain Injury by Prophylactic Diet Supplementation in Mice. Nutrients 2019; 11:nu11020299. [PMID: 30708954 PMCID: PMC6412510 DOI: 10.3390/nu11020299] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 02/08/2023] Open
Abstract
Currently, there are no approved therapeutic drugs for the treatment of traumatic brain injury (TBI), and new targets and approaches are needed to provide relief from the long-term effects of TBI. Recent studies suggest that nutrition plays a critical role in improving the outcome from TBI in both civilians and military personnel. We have previously shown that GrandFusion® (GF) diets improved recovery from cerebral ischemia and enhanced physical activity and endurance in rodent models. We, therefore, sought to determine the impact of a prophylactic diet enriched in fruits and vegetables on recovery from TBI in the controlled cortical impact rodent model. Results demonstrated that mice fed the diets had improved neuromotor function, reduced lesion volume, increased neuronal density in the hippocampus and reduced inflammation. As previously shown, TBI increases cathepsin B as part of the inflammasome complex resulting in elevated inflammatory markers like interleukin-1β (IL-1β). Consumption of the GF diets attenuated the increase in cathepsin B levels and prevented the increase in the proapoptotic factor Bax following TBI. These data suggest that prior consumption of diets enriched in fruits and vegetables either naturally or through powdered form can provide protection from the detrimental effects of TBI.
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Affiliation(s)
- Jin Yu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | - Hong Zhu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | - Saeid Taheri
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | - William L Monday
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
| | | | - Mark S Kindy
- Department of Pharmaceutical Sciences, College of Pharmacy, University of South Florida, Tampa, FL 33620, USA.
- Departments of Molecular Medicine, Molecular Pharmacology, Physiology and Pathology and Cell Biology, and Neurology, College of Medicine, University of South Florida, Tampa, FL 33620, USA.
- James A. Haley VA Medical Center, Tampa, FL 33612, USA.
- Shriners Hospital for Children, Tampa, FL 33612, USA.
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Jeong HB, Park SH, Ryu HG. Nutritional Support for Neurocritically Ill Patients. JOURNAL OF NEUROCRITICAL CARE 2018. [DOI: 10.18700/jnc.180070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Virani FR, Peery T, Rivas O, Tomasek J, Huerta R, Wade CE, Lee J, Holcomb JB, Uray K. Incidence and Effects of Feeding Intolerance in Trauma Patients. JPEN J Parenter Enteral Nutr 2018; 43:742-749. [PMID: 30508254 DOI: 10.1002/jpen.1469] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 10/09/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although feeding intolerance is a common complication in trauma patients, the incidence, development, and effects are poorly understood. METHODS We performed a retrospective study in which trauma patients were classified as having feeding intolerance based on time to reach feeding goal. Subsequently, we sorted patients by gastric residual volumes (GRVs) or symptoms of slowed gastrointestinal motility. RESULTS One-third of trauma patients experienced delayed time to reach feeding goal after diet initiation. Delayed feeding was associated with prolonged intensive care unit (ICU) stays, increased readmission rates, and increased incidence of sepsis. Patients with elevated GRV (>500 mL) had significantly prolonged ICU and hospital stays and increase incidence of sepsis. Patients with >2 symptoms of slowed gastrointestinal motility had prolonged ICU and hospital stays, delayed time to reach feeding goals, significantly increased readmission rates, increased incidence of infectious and thromboembolic complications and sepsis, decreased serum prealbumin levels, and increased CRP levels. CONCLUSION Decreased gastrointestinal motility in trauma patients is associated with worse outcomes and increased systemic inflammation.
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Affiliation(s)
- Farrukh R Virani
- Department of Otolaryngology, University of California Davis Medical Center, Sacramento, California, USA
| | - Travis Peery
- Department of Internal Medicine, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA
| | - Orlyn Rivas
- Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jeffrey Tomasek
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA
| | - Ravin Huerta
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA
| | - Charles E Wade
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA.,Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA
| | - Jenny Lee
- Memorial Hermann Red Duke Trauma Institute, Houston, Texas, USA.,Department of Clinical Nutrition, Memorial Hermann Hospital, Houston, Texas
| | - John B Holcomb
- Department of Surgery and Center for Translational Injury Research, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA
| | - Karen Uray
- Department of Medical Chemistry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury. Neurocrit Care 2018; 27:276-286. [PMID: 28004327 DOI: 10.1007/s12028-016-0336-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.
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Farrell D, Bendo AA. Perioperative Management of Severe Traumatic Brain Injury: What Is New? CURRENT ANESTHESIOLOGY REPORTS 2018; 8:279-289. [PMID: 30147453 PMCID: PMC6096919 DOI: 10.1007/s40140-018-0286-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF THE REVIEW Severe traumatic brain injury (TBI) continues to represent a global public health issue, and mortality and morbidity in TBI patients remain substantial. There are ongoing international collaborations to provide guidelines for perioperative care and management of severe TBI patients. In addition, new pharmacologic agents are being tested along with cognitive rehabilitation to improve functional independence and outcome in TBI patients. This review will discuss the current updates in the guidelines for the perioperative management of TBI patients and describe potential new therapies to improve functional outcomes. RECENT FINDINGS In the most recent guidelines published by The Brain Trauma Foundation, therapeutic options were reviewed based on new and revised evidence or lack of evidence. For example, changes and/or updates were made to the recommendations for the use of sedation and hypothermia in TBI patients, and new evidence was provided for the use of cerebrospinal fluid drainage as a first-line treatment for increased intracranial pressure (ICP). In addition to the guidelines, new 'multi-potential' agents that can target several mechanisms are being tested along with cognitive rehabilitation. SUMMARY The major goal of perioperative management of TBI patients is to prevent secondary damage. Therapeutic measures based on established guidelines and recommendations must be instituted promptly throughout the perioperative course to reduce morbidity and mortality.
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Affiliation(s)
- Deacon Farrell
- Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Avenue, Box 6, Brooklyn, New York 11203 USA
| | - Audrée A. Bendo
- Downstate Medical Center, State University of New York (SUNY), 450 Clarkson Avenue, Box 6, Brooklyn, New York 11203 USA
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Ndoumbe A, Ngoyong Edu PB, Simeu C, Takongmo S. Epidemiological Analysis of 135 Cases of Severe Traumatic Brain Injury Managed at a Surgical Intensive Care Unit. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/ojmn.2018.81010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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Abstract
Traumatic brain injury remains a serious public health problem, causing death and disability for millions. In order to maximize outcomes in the face of a complex injury to a complex organ, a variety of advanced neuromonitoring techniques may be used to guide surgical and medical decision-making. Because of the heterogeneity of injury types and the plethora of treatment confounders present in this patient population, the scientific study of specific interventions is challenging. This challenge highlights the need for a firm understanding of the anatomy and pathophysiology of brain injuries when making clinical decisions in the intensive care unit.
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Abstract
Head trauma is a common cause of significant morbidity and mortality in dogs and cats. Traumatic brain injury may occur after head trauma. Understanding the pathophysiology of primary and secondary injury after head trauma is essential for management. This article reviews the pathophysiology of head trauma, patient assessment and diagnostics, and treatment recommendations.
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Affiliation(s)
- Kendon W Kuo
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA.
| | - Lenore M Bacek
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA
| | - Amanda R Taylor
- Neurology/Neurosurgery, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA
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Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in patients with trauma. Management strategies must focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow. CPP can be maintained by increasing mean arterial pressure, decreasing intracranial pressure, or both. The goal should be euvolemia and avoidance of hypotension. Other factors that deserve important consideration in the acute management of patients with TBI are venous thromboembolism, stress ulcer, and seizure prophylaxis, as well as nutritional and metabolic optimization.
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Affiliation(s)
- Michael A. Vella
- Chief Resident in General Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Medical Center North, CCC-4312, 1161 21st Avenue South, Nashville, TN 37232-2730,
| | - Marie Crandall
- Professor of Surgery, Division of Acute Care Surgery, Department of Surgery, University of Florida, Jacksonville, 655 West 8th Street, Jacksonville, FL 32209,
| | - Mayur B. Patel
- Assistant Professor of Surgery, Neurosurgery, Hearing & Speech Sciences, Division of Trauma, Surgical Critical Care, and Emergency General Surgery, Department of Surgery, Section of Surgical Sciences, Center for Health Services Research, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 21 Avenue South, Medical Arts Building, Suite 404, Nashville, TN 37212,
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Dickerman R, Reynolds A, Williamson J, Winters K. Letter: Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 81:E50. [DOI: 10.1093/neuros/nyx308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
BACKGROUND Brain Trauma Foundation guidelines recommend the early use of enteral nutrition to optimize recovery following traumatic brain injury (TBI). Our aim was to examine the effect of early feeds (≤24 hours) on clinical outcomes after TBI. METHODS We performed a 3-year retrospective study of patients with severe TBI (Glasgow Coma Scale score <8) who were intubated, admitted to the intensive care unit (ICU), and received tube feeds. Early tube feeds (early TF) were defined as initiation of tube feeds within 24 hours, whereas late tube feeds (late TF) were defined as initiation of tube feeds after 24 hours. Outcome measures included pneumonia rates, days on ventilator, hospital and ICU stay, and mortality rates. RESULTS A total of 90 patients (early TF: 58, late TF: 32) were included, of which 73.3% were male, mean age was 42 (SD, 20) years, and median head Abbreviated Injury Scale score was 4 (range, 3-5). There was no difference in age (p = 0.1), head Abbreviated Injury Scale score (p = 0.5), or admission Glasgow Coma Scale score (p = 0.9) between the two groups. Patients with early TF were associated with higher number of ICU days (p = 0.03) and higher pneumonia rates (p = 0.04), but there was no significant difference in mortality (p = 0.44) as compared with those who underwent late TF. CONCLUSIONS Although early tube feeds are known to improve outcomes in TBI patients, our data suggest that early feeds in TBI patients are associated with higher rates of pneumonia and greater hospital resource utilization. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Effects of Synbiotic2000™ Forte on the Intestinal Motility and Interstitial Cells of Cajal in TBI Mouse Model. Probiotics Antimicrob Proteins 2017; 9:172-181. [PMID: 28303478 DOI: 10.1007/s12602-017-9266-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The main objective of this study was to investigate the effects of Synbiotic2000™ Forte on the intestinal motility and interstitial cells of Cajal (ICC) in traumatic brain injury (TBI) mouse model. Kunming mice were randomly divided into sham operation group (S group), enteral nutrition group with TBI (E group), and Synbiotic2000™ Forte group with TBI (P group). The contractile activity of the intestinal smooth muscle, densities and ultrastructure of the ICC, kit protein concentration, weight, and defecation of mice were monitored and analyzed. TBI markedly suppressed contractile activity of the intestinal smooth muscle (P < 0.01), which led to a reduction of defecation (P < 0.01) and weight (P < 0.01). However, application of Synbiotic2000™ Forte significantly improved contractile activity of the small intestine (P < 0.01), which may be related to protective effects to the interstitial cells of Cajal, smooth muscle cells, and enteric neurons. TBI impaired ICC networks and densities (P < 0.01), events that were protected by the application of Synbiotic2000™ Forte. Synbiotic2000™ Forte may attenuate TBI-mediated inhibition of the kit protein pathway. Synbiotic2000™ Forte may improve intestinal motility and protect the ICC in the TBI mouse. These findings provide a novel support for the application of Synbiotic2000™ Forte in intestinal motility disturbance after TBI.
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Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GWJ, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80:6-15. [PMID: 27654000 DOI: 10.1227/neu.0000000000001432] [Citation(s) in RCA: 1918] [Impact Index Per Article: 274.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 08/14/2016] [Indexed: 12/13/2022] Open
Abstract
The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.
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Affiliation(s)
- Nancy Carney
- Oregon Health & Science University, Portland, Oregon
| | | | | | - Jamie S Ullman
- Hofstra North Shore-LIJ School of Medicine, Hempstead, New York
| | | | | | | | | | | | - Niranjan Kissoon
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andres M Rubiano
- El Bosque University, Bogota, Colombia
- MEDITECH Foundation, Neiva, Colombia
| | - Lori Shutter
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Harvard Medical School & Boston Children's Hospital, Boston, Massachusetts
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The impact of measurement of respiratory quotient by indirect calorimetry on the achievement of nitrogen balance in patients with severe traumatic brain injury. Eur J Trauma Emerg Surg 2016; 43:775-782. [PMID: 27658944 DOI: 10.1007/s00068-016-0724-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 09/10/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND This study evaluated the impact of IC on the optimization of nutritional support and the achievement of +NB in patients with TBI. MATERIALS AND METHODS 27 patients (GCS ≤ 8), treated with a 5-day multimodality monitoring and goal-directed therapy protocol, received enteral nutrition on day 1 followed by IC on days 3 and 5 and assessment of NB on day 7. In the first cohort (n = 11), no adjustment in kcal was made. In the second cohort (n = 16), nutrition was targeted to an RQ of 0.83 by day 3. The first cohort was analyzed with respect to NB status; the second cohort was compared to patients with (-) and +NB of the first cohort. Data (mean ± SD) were analyzed with unpaired t test, and Chi square and Fisher exact tests. RESULTS 4/11(36 %) patients in the first cohort had +NB. The predicted mortality by TRISS, substrate utilization, and RQ was significantly lower compared to the second cohort. The mortality predicted by the CrasH model did not differ between the two cohorts. A RQ of 0.74 was associated with the preferential use of fat and protein and -NB, whereas a RQ of 0.84 favored utilization of carbohydrates and +NB. All patients whose kcal intake was adjusted based on the RQ on day 3 reached a +NB by day 7. CONCLUSION An increase in kcal ≥25 % in patients with a RQ < 0.83 on day 3 improves substrate utilization, decreases protein utilization and optimizes the achievement of +NB by day 7.
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Nutrition Therapy in the Organ Donor: Theoretical Benefits and Barriers to Implementation. Curr Nutr Rep 2016. [DOI: 10.1007/s13668-016-0170-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Potapov AA, Krylov VV, Gavrilov AG, Kravchuk AD, Likhterman LB, Petrikov SS, Talypov AE, Zakharova NE, Oshorov AV, Sychev AA, Alexandrova EV, Solodov AA. [Guidelines for the diagnosis and treatment of severe traumatic brain injury. Part 2. Intensive care and neuromonitoring]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 80:98-106. [PMID: 27029336 DOI: 10.17116/neiro201680198-106] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic brain injury (TBI) is one of the major causes of death and disability in young and middle-aged people. The most problematic group is comprised of patients with severe TBI who are in a coma. The adequate diagnosis of primary brain injuries and timely prevention and treatment of the secondary injury mechanisms largely define the possibility of reducing mortality and severe disabling consequences. When developing these guidelines, we used our experience in the development of international and national recommendations for the diagnosis and treatment of mild traumatic brain injury, penetrating gunshot wounds to the skull and brain, severe traumatic brain injury, and severe consequences of brain injuries, including a vegetative state. In addition, we used international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe traumatic brain injury, which had been published in recent years. The proposed guidelines concern intensive care of severe TBI in adults and are particularly intended for neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in the treatment of these patients.
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Affiliation(s)
- A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V V Krylov
- Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russia
| | - A G Gavrilov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A D Kravchuk
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - S S Petrikov
- Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russia
| | - A E Talypov
- Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russia
| | | | - A V Oshorov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A A Sychev
- Burdenko Neurosurgical Institute, Moscow, Russia, Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russia
| | | | - A A Solodov
- Sklifosovsky Research Institute of Emergency Medicine, Moscow, Russia
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Lončarević-Vasiljković N, Milanović D, Pešić V, Tešić V, Brkić M, Lazić D, Avramović V, Kanazir S. Dietary restriction suppresses apoptotic cell death, promotes Bcl-2 and Bcl-xl mRNA expression and increases the Bcl-2/Bax protein ratio in the rat cortex after cortical injury. Neurochem Int 2016; 96:69-76. [DOI: 10.1016/j.neuint.2016.02.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/23/2016] [Accepted: 02/26/2016] [Indexed: 12/31/2022]
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med 2016; 44:390-438. [PMID: 26771786 DOI: 10.1097/ccm.0000000000001525] [Citation(s) in RCA: 384] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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