Glucose variability negatively impacts long-term functional outcome in patients with traumatic brain injury

Purpose

Significant glycemic excursions (so-called glucose variability) affect the outcome of generic critically ill patients but has not been well studied in patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the impact of glucose variability on long-term functional outcome of patients with TBI.

Material and Methods

A noncomputerized tight glucose control protocol was used in our intensivist model surgical intensive care unit. The relationship between the glucose variability and long-term (a median of 6 months after injury) functional outcome defined by extended Glasgow Outcome Scale (GOSE) was analyzed using ordinal logistic regression models. Glucose variability was defined by SD and percentage of excursion (POE) from the preset range glucose level.

Results

A total of 109 patients with TBI under tight glucose control had long-term GOSE evaluated. In univariable analysis, there was a significant association between lower GOSE score and higher mean glucose, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL but not POE 80 to 110. After adjusting for possible confounding variables in multivariable ordinal logistic regression models, higher SD, POE more than 60, POE 80 to 150, and single episode of glucose less than 60 mg/dL were significantly associated with lower GOSE score.

Conclusions

Glucose variability was significantly associated with poorer long-term functional outcome in patients with TBI as measured by the GOSE score. Well-designed protocols to minimize glucose variability may be key in improving long-term functional outcome.     

高压氧治疗对大鼠重度脑创伤后炎性反应的影响

目的观察高压氧治疗对重度脑创伤大鼠其脑组织内炎性细胞因子水平的影响及大鼠脑组织病理学改变,并探讨高压氧治疗的作用机制。方法将SD大鼠随机分为假手术组、高压氧组及脑创伤组。采用高压气体冲击脑组织制作大鼠局部脑创伤模型。分别于术后3h、1d、3d、5d及7d时观察大鼠脑组织病理学改变;同时应用放射免疫检测技术测定脑创伤组及高压氧组在上述各时间点时脑内TNF-α、IL-6、IL-8及IL-10的水平。结果当大鼠发生脑创伤后,上述各炎性细胞因子水平较假手术组均有不同程度提高,经高压氧治疗后,发现炎性细胞向脑组织内浸润现象减缓,并有大量小胶质细胞、星形胶质细胞聚集、增生,而且高压氧组大鼠脑组织内上述炎性细胞因子在各时间点均较脑创伤组降低(均P<0.01);与假手术组比较,差异无统计学意义(P>0.05)。结论高压氧可抑制炎性细胞向脑创伤组织处浸润,降低各炎性细胞因子水平,促进小胶质细胞、星形胶质细胞聚集、增生,具有保护受损脑组织的功效。     

高压氧对脑外伤大鼠额叶皮质和海马胆碱乙酰转移酶阳性神经元数目的影响

目的观察高压氧（HBO）对脑外伤大鼠额叶皮质和海马胆碱乙酰转移酶（ChAT）阳性神经元数目的影响。方法采用自由落体撞击法造模。将30只大鼠随机分为假手术对照组（A组）、脑外伤组（B组）和脑外伤加HBO治疗组（C组），各组大鼠在造模24d后同时进行ChAT阳性细胞数及相关参数的定量分析。结果C组大鼠额叶皮质和海马ChAT阳性神经元数目比B组明显增多（P〈0．01）。结论HBO治疗能抑制乙酰胆碱能神经元的退行性变，从而使损伤大鼠海马区ChAT阳性纤维增生。这可能是HBO治疗改善颅脑损伤大鼠学习记忆功能障碍的原因。     

Intracranial pressure complicating severe traumatic brain injury in children: monitoring and management

Objective To identify factors associated with the use of intracranial pressure (ICP) monitoring and to establish which ICP-targetted therapies are being used in children with severe traumatic brain injury (TBI) in the United Kingdom. To evaluate current practice against recently published guidelines.Design and setting Prospective data collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Ireland admitting children (< 16 years) with TBI between February 2001 and August 2003.Results Detailed clinical information was obtained for 501 children, with information on the use of ICP monitoring available in 445. ICP monitoring was used in only 59% (75/127) of children presenting with an emergency room Glasgow Coma Scale of 8 or below. Large between centre variation was seen in the use of ICP monitoring, independent of severity of injury. There were 86 children who received ICP-targetted therapies without ICP monitoring. Wide between centre variation was found in the use of ICP-targetted therapies and in general aspects of management, such as fluid restriction, the use of muscle relaxants and prophylactic anticonvulsants. Intra-ventricular catheters are rarely placed (6% of cases); therefore cerebrospinal fluid drainage is seldom used as a first-line therapy for raised ICP. Jugular venous bulb oximetry (4%), brain microdialysis (< 1%) and brain tissue oxygen monitoring (< 1%) are rarely used in current practice. Contrary to published guidelines, moderate to severe hyperventilation is being used without monitoring for cerebral ischaemia.Conclusions There is an urgent need for greater standardisation of practice across UK centres admitting children with severe TBI.This study was supported by grants from the Paediatric Intensive Care Society, Birmingham Children's Hospital Research Foundation and the Warwick University Research and Teaching Development Fund.     

创伤性颅脑损伤后神经细胞凋亡的研究

目的：通过对创伤性颅脑损伤后神经细胞凋亡的研究，了解人脑创伤后脑组织中凋亡发生的情况及其所起的作用。方法：采用末端脱氧核苷酸转移酶介导的d-UTP生物素标记法(TUNEL法)检测细胞凋亡。同时显微镜观察病理切片。结果：66．7％出现TUNEL阳性，TUNEL阳性与阴性患者间的GCS评分(t=-2.88，P=O．01)、受伤时间(t=2．14，P=0．049)有显著差异。TUNEL阳性与阴性患者间性别、年龄、预后无显著差异。结论：人脑创伤后脑组织中存在凋亡，且与患者的病情严重程度及病程相关。其在颅脑创伤的病理过程中有一定作用，但只是颅脑损伤后复杂病理过程中的一种表现，即创伤后神经细胞死亡的一种方式。     

Intensivists’ response to hyperoxemia in mechanical ventilation patients: The status quo and related factors

BACKGROUND: Due to the still sparse literature in China, the investigation of hyperoxemia management is required. Thus, we aim to conduct a retrospective study to provide more information about hyperoxemia management in intensive care unit (ICU) patients.     

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

Objective: To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients’ preinjury sociodemographic data, injury-related and postinjury factors.

Design: A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

Methods: The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

Results: At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale–Extended score.

Conclusion: This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work.

• Implications for rehabilitation

• Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss.

• Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients.

• The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation.

• The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

     

奥拉西坦联合高压氧治疗颅脑损伤疗效观察

目的观察奥拉西坦联合高压氧治疗颅脑损伤的临床效果。方法 90例颅脑损伤患者随机分为观察组和对照组各45例,在常规治疗基础上,观察组给予奥拉西坦联合高压氧治疗,对照组静脉滴注奥拉西坦,2组均连续治疗21d。比较2组治疗前、后格拉斯哥昏迷量表（Glasgow Coma Scale,GCS）、意识觉醒恢复时间及疗效,观察2组治疗后简易精神状态检查量表（Minimum Mental State Examination,MMSE）和神经功能缺损评分表（National Institutes of Health Stroke Scale,NIHSS）变化。结果观察组总有效率（88.89%）高于对照组（73.11%）,意识觉醒恢复时间（（6.29±0.94）d）短于对照组（（8.16±0.82）d）（P〈0.01）;2组治疗后GCS评分均较治疗前增高（P〈0.05）;观察组治疗后MMSE评分（（22.38±0.96）分）高于对照组（（21.64±1.15）分）（P〈0.01）,NIHSS评分（（10.80±1.16）分）低于对照组（（12.87±0.92）分）（P〈0.01）;2组均未发生不良反应。结论奥拉西坦联合高压氧治疗颅脑损伤疗效优于单独应用奥拉西坦,且无不良反应。     

Coagulopathy as a predictor of mortality after penetrating traumatic brain injury

Study hypothesis

Traumatic brain injury (TBI) is a leading cause of mortality with penetrating TBI (p-TBI) patients having worse outcomes. These patients are more likely to be coagulopathic than blunt TBI (b-TBI) patients, thus we hypothesize that coagulopathy would be an early predictor of mortality.

颅脑创伤型下丘脑垂体功能不全的临床研究

目的 研究颅脑创伤(TBI)后垂体前叶激素(APHs)、甲状腺功能(TF)和生殖激素(GnH)的动态变化及其临床意义. 方法 随机对浙江省人民医院2006年3月至2007年6月经系列头颅CT扫描和/或MRI检查,明确无下丘脑、垂体等部位的原发损伤,且既往无中枢神经系统、内分泌和泌尿生殖系统肿瘤及免疫性疾患史的93例门急诊和住院TBI患者的APHs、TF和GnH进行测定,并按患者的GCS评分、TBI类型和损伤程度以及有无继发性脑损害等因素进行分组研究,以同期20例健康体检者作为对照组.采用SPSS 11.5软件进行分析,多变量采用成组Hotelling T2检验,两组均数间比较采用t检验,P<0.05为差异具有统计学意义. 结果 93例患者人院就诊时的促肾上腺皮质激素(ACTH)、黄体生成素(LH)和泌乳素(PRL)水平明显高于出院随访期和对照组(P<0.05),促甲状腺素(TSH)和甲状腺激素T3、T4和游离T3(FT3)水平则明显低于出院随访期和对照组(P<0.05).有继发性脑损害组的血清ACTH值和PRL值分别高达(33.33±6.86)和(31.74±5.51),GCS 9～12分组的血清LH值为(9.48±1.14);颅脑损伤组的血清TSH值(1.26±0.17)明显低于对照组和其他各组(P<0.05).除TSH、PRL、睾酮(T)和雌二醇(E2),患者出院随访期其他血清APHs值均明显低于正常对照组(P<0.05).单项APH水平低下的创伤型下丘脑垂体功能不全(THPI)的发生率为13.8%,同时累及3种以上APHs的THPI发生率仅为3.2%;正常甲状腺功能病态综合征(SETS)的发生率为14.0%. 结论 THPI以单项APH分泌障碍型多见.颅脑创伤所致的急性颅内高压以及脑水肿、脑缺血等继发性脑损害可能是导致删的主要原因;TBI后早期的高PRL血症是提示THPI的重要指标,TBI后激素水平的动态变化可作为激素疗法的重要依据.     

重型颅脑外伤患者呼吸机相关性肺炎的因素分析与护理干预

目的:探讨重型颅脑外伤患者呼吸机相关性肺炎的因素分析和护理方法,减少机械相关性肺炎的发生。方法:将2009年1月～2011年12月入住我院重型颅脑外伤65例患者随机分为干预组33例和对照组32例,分别采用综合护理干预方法和常规护理方法,比较其机械相关性肺炎发生情况。结果:影响重型颅脑外伤患者呼吸机相关性肺炎的因素有年龄、住院天数、呼吸机应用天数、气管切开、休克患者、心肺基础病;采用综合护理干预方法的患者VAP发生率低于采用常规护理的患者(P<0.05)。结论:对机械通气患者行综合护理干预,能有效减少重型颅脑外伤患者机械通气相关性肺炎的发生率,有一定的临床意义,值得普遍推广。     

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

Purpose.?To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

Method.?This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7–24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

Results.?Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

Conclusions.?The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.     

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

Purpose. To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

Method. This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7-24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

Results. Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

Conclusions. The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.     

颅脑损伤术后精神障碍200例临床分析

目的 探讨外伤性精神障碍与脑叶损伤部位的关系及外伤性精神障碍的愈后。方法通过对200例因颅脑损伤开颅术后出现精神障碍患者的临床资料分析判定外伤性精神障碍与脑叶损伤具体部位的关系及愈后情况。结果单纯额叶损伤69例,单纯颞叶损伤65例,额、颞叶均损伤56例,合并下丘脑损伤10例,以左侧半球损伤为主占124例,以右侧半球损伤为主占76例。随访至术后6个月：痊愈141例,显著好转29例,好转24例,无效6例。结论外伤性精神障碍的出现与脑叶损伤部位密切相关,均损伤了人脑的精神活动中枢且通过积极的综合治疗,愈后良好。     

脑外伤后进展性出血性损伤的影响因素分析

目的 探讨脑外伤后进展性出血性损伤(PHI)发生的影响因素.方法 回顾性分析127例颅脑损伤患者(PHI组49例,非PHI组78例)的临床资料,比较不同性别、年龄、格拉斯哥昏迷计分、伤后首次头颅CT检查时间、创伤性蛛网膜下腔出血(tSAH)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)等因素对PHI发生的影响.结果 PHI组首次CT时间(1.39±1.27)h,非PHI组(2.91±1.85)h,2组比较差异有统计学意义(t=2.14,P<0.05).PHI组发生tSAH 35例,非PHI组发生37例,2组tSAH发生率差异有统计学意义(χ2=7.06,P<0.05).多因素Logistic回归分析结果表明,伤后首次行头颅CT检查的时间以及伴有tSAH与脑外伤后PHI的发生有密切关系(OR值0.558,95%CI 0.329～0.946,OR值13.000,95%CI1.187～142.354,P均<0.05).结论 颅脑损伤后首次CT检查的时间以及tSAH可以作为PHI发生的预判指标.     

Admission of patients with severe and moderate traumatic brain injury to specialized ICU facilities: a search for triage criteria

Objective To investigate whether triage for direct admission of patients with traumatic brain injury to a trauma center is facilitated by predicting the risk of potentially removable lesions or raised intracranial pressure (ICP).Design and setting Cohort study in a level I university trauma center.Patients and participants A prospective cohort of primarily (n=200) and secondarily (n=75) referred patients with moderate or severe traumatic brain injury.Measurements and results Predictive characteristics for the risk of surgically removable lesions and the risk of raised ICP (repeatedly 20 mmHg) were identified and included in prognostic models. These models were validated internally with bootstrapping techniques and externally on a historic sample (n=205) regarding discriminative ability (AUC). Among the cohort patients, 67% had raised ICP and 54% had surgically removable lesions. Both outcomes occurred more frequently in patients secondarily referred, but the incidence in patients primarily referred was also high (62% and 33% respectively). No strong predictors of raised ICP were identified. Age and pupillary reactivity were significant predictors of surgically removable lesions. The models discriminated reasonably for surgically removable lesions (AUC=0.78 at development and AUC=0.67 at external validation) but not for raised ICP (AUC=0.59 at development and AUC=0.50 at external validation).Conclusions It is difficult accurately to identify patients in need of specialized intensive care using baseline characteristics. The high incidence of both outcomes in patients primarily referred support direct admission of more and particularly older patients with severe or moderate brain trauma to level I trauma centers.     

高压氧配合康复治疗对颅脑外伤偏瘫肢体运动功能的影响

目的探讨高压氧配合康复治疗对颅脑外伤偏瘫肢体运动功能的影响。方法 72例颅脑外伤患者根据随机数字表法分为治疗组和对照组各36例,治疗组采用高压氧配合康复治疗,对照组采用常规康复治疗,观察治疗前后运动功能、躯干控制能力、平衡能力、生活质量指数的变化,结果采用SPSS 13.0统计学软件进行分析。结果治疗后两组患者的肢体运动功能、躯干控制能力、平衡能力、生活质量均有提高,治疗组提高更显著,与对照组比较,差异有统计学意义（P（0.01）。结论高压氧配合康复治疗有利于颅脑外伤患者的肢体运动功能的恢复,提高患者的生活质量。     

重型颅脑损伤后脑积水原因及其治疗

目的 分析重型颅脑损伤后脑积水的原因和治疗体会。方法 对我院18例重型颅脑损伤后脑积水的临床资料进行回顾性分析。结果 经治疗后本组18例患者中恢复良好12例，中残3例，重残2例，死亡l例。结论 分析脑积水原因，并针对其病因和积水不同时期，采取相应的措施，如侧脑室外引流，病因治疗或行内分流术。