Objective:The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.Design:Randomized clinical trial.Set

Prevention of secondary ischemic insults after severe head injury.

Traumatic brain injury (TBI) is a major medical and socio-economic problem, and is the leading cause of death in children and young adults. The critical care management of severe TBI is largely derived from the "Guidelines for the Management of Severe Traumatic Brain Injury" that have been published by the Brain Trauma Foundation. The main objectives are prevention and treatment of intracranial hypertension and secondary brain insults, preservation of cerebral perfusion pressure (CPP), and optimization of cerebral oxygenation. In this review, the critical care management of severe TBI will be discussed with focus on monitoring, avoidance and minimization of secondary brain insults, and optimization of cerebral oxygenation and CPP.

/pdf/critical-care-management-of-severe-traumatic-brain-injury-in-4wvd9dps2p.pdf

Critical care management of severe traumatic brain injury in adults

Traumatic brain injury (TBI) remains a major cause of morbidity and mortality, particularly in young people. Despite encouraging animal studies, human trials assessing the use of pharmacological agents after TBI have all failed to show efficacy. Current management strategies are therefore directed towards providing an optimal physiological environment in order to minimize secondary insults and maximize the body's own regenerative processes. Modern neurocritical care management utilizes a host of monitoring techniques to identify or predict the occurrence of secondary insults and guide subsequent therapeutic interventions in an attempt to minimize the resulting secondary injury. Recent data suggest that the use of protocolized management strategies, informed by multimodality monitoring, can improve patient outcome after TBI. Developments in multimodality monitoring have allowed a movement away from rigid physiological target setting towards an individually tailored, patient-specific, approach. The wealth of monitoring information available provides a challenge in terms of data integration and accessibility and modern software applications may aid this process.

Multimodal monitoring in traumatic brain injury: current status and future directions

ObjetiveThis study was performed to examine both brain and systemic interleukin-6 (IL-6) release in patients with an acute brain injury (ABI), to study whether a correlation exists between the transcranial IL-6 gradient during the first days after injury and prognosis, and finally, to investigate th

Correlation between transcranial interleukin-6 gradient and outcome in patients with acute brain injury.

OBJECTIVE: Uncoupling of cerebral blood flow (CBF) and oxidative metabolism is observed after severe head injury in comatose patients; however, the mechanism(s) involved remain undefined. Adenosine can produce cerebral vasodilation and reduce neuronal activity and is a possible mediator of uncoupling. We hypothesized that cerebrospinal fluid (CSF) adenosine concentrations would be increased during uncoupling of CBF and oxidative metabolism, defined as a narrow arterio-jugular venous oxygen difference [D(a - v)0 2 4 vol%] after head injury. METHODS: Adenosine concentrations were measured using fluorescent-based high-pressure liquid chromatography in 67 CSF samples obtained from 13 comatose (Glasgow Coma Scale score 7) adult patients who sustained a severe closed head injury. At the time each sample was obtained, CBF was measured by the xenon-133 method, and blood samples were obtained for determination of D(a - v)O 2 . RESULTS: CSF adenosine concentration was negatively associated with D(a - v)0 2 (P 4 vol% (38.5 [3.2-306.3] versus 14.0 [2.7-795.5] nmol/L, respectively, median [range]; P < 0.025) and in patients who died versus survivors (40.1 [6.9-306.3] versus 12.9 [2.7-795.5] nmol/L, respectively, median [range]; P < 0.001). CONCLUSION: The association between increased CSF adenosine concentration and a reduction in global cross-brain extraction of oxygen supports a regulatory role for adenosine in the complex balance between CBF and oxidative and nonoxidative metabolism after severe head injury in humans.

Cerebrospinal fluid adenosine concentration and uncoupling of cerebral blood flow and oxidative metabolism after severe head injury in humans.

Venous oxygen saturation at the clinically dominant jugular bulb (SjO2) and that at the confluence of the cerebral sinuses (SCCSO2) were compared by direct simultaneous blood sampling of 13 severely head injured patients. The side of dominant jugular bulb (JB) was determined by neck compression test. The right side was chosen if the test was equivocal. In effect, the right side was cannulated in all cases. Subsequent angiography showed that two of the 13 cases were left side dominant. In all, 176 pairs of blood samples were analysed. Correspondence rates (the difference between each pair of blood samples being less than 4% of oxygen saturation) for individual case were good (80-100%) in nine cases including one case with left side dominance. Correspondence rates were moderate in two cases (50 and 56%); the differences were not clinically significant. In the remaining two cases, including one with left side dominance, the correspondence rates were poor (0 and 4%, respectively); SCCSO2 was always lower than...

Cerebral venous oxygen saturation monitoring : is dominant jugular bulb cannulation good enough ?

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Cerebral venous oxygen saturation monitoring : is dominant jugular bulb cannulation good enough ?