ICP threshold in CPP management of severe head injury patients

BACKGROUND: Elevated intracranial pressure (ICP) is significantly associated with high mortality rate in severe head injury (SHI) patients. However, there is no absolute agreement regarding the level at which ICP must be treated. The objective of this study was to compare the outcomes of severe head injury patients treated by setting the ICP threshold at >or=20 mm Hg or >or=25 mm Hg. METHODS: Treatment protocol in this study consisted of therapeutic maneuvers designed to maximize cerebral profusion pressure (CPP) and control ICP. Twenty-seven patients with severe head injury and intracranial hypertension (ICP >or=20 mm Hg) were enrolled and fourteen cases were allocated to the group of ICP threshold >or=25 mm Hg. Six-month clinical outcomes were evaluated using the Glasgow Outcome Score (GOS). RESULTS: There were no statistically significant differences in clinical parameters between the groups. Logistic regression identified the presence of basal cisterns on the initial computed tomography (CT) scan as a significant predictor of good outcome. ICP threshold did not influence outcome. CONCLUSIONS: This study supported a recommended ICP threshold of 20 to 25 mm Hg in SHI management. However, in cases with an absence of basal cisterns on initial CT scan, the probability of good outcome may be higher using an ICP threshold of >or=20 mm Hg.     

Indomethacin: its role in the management of intractable intracranial pressure (ICP) after severe head injury

Intracranial hypertension that fails to respond to first linemedical and surgical treatment after head injury is associatedwith a 92% mortality overall.¹ The addition of barbiturateswill result in a good or moderate neurological outcome in 35%of patients,² but those with hyperaemia do significantly worse.However barbiturates may not be a logical choice for those patientswhose intracranial hypertension is secondary to hyperaemia,and may be associated with significant complications. In thesepatients cerebral vasoconstrictors such as indomethacin maybe more appropriate and possibly associated with fewer unwantedeffects. In one study six out of 10 patients who received indomethacinfor intracranial hypertension unresponsive to barbiturates survived.³However it is unclear how many were hyperaemic since jugularvenous saturation (Sj_O2) was not monitored. We report our experiencewith indomethacin in 10 severely head-injured patients. Our protocol aims to maintain a target cerebral perfusion pressure(CPP) and ICP through the application of sedation, diuretics,CSF drainage, mild hypothermia, muscle relaxation and controlof arterial carbon dioxide (Pa_CO2). If the ICP remains elevatedthen Sj_O2 is monitored. The combination of raised ICP and Sj_O2is taken to indicate hyperaemia (absolute or relative). In thesecircumstances the patient is hyperventilated to a Pa_CO2 of 28mmHg and if necessary an intravenous infusion of thiopentonecommenced. We used indomethacin infusions in 10 patients fulfillingthese criteria of hyperaemia. In seven patients the hyperaemiawas confirmed as absolute by demonstrating a raised middle cerebralartery velocity (MCAV) with transcranial Doppler. The mean ageof the patients was 21.2 yr (range 8–55). Indomethacinwas infused for a mean of 3.8 days (1–11) at a rate of3–11 mg h^–1. The effect of indomethacin on mean(SD) ICP, CPP and Sj_O2 is shown in Table 4. At 6-month follow up there were seven survivors (three goodrecovery, three moderate recovery, one severely disabled). Threepatients died with intractable ICP and septic shock. Two ofthese patients had associated renal failure. There were no episodesof gastrointestinal bleeding. Two of the three patients whodied did not have MCAV measured, and therefore indomethacinmay not have been strictly indicated. These results achievedin this subgroup of head injured patients is much better thanthat expected, and matches the outcome achieved in the overallICU head injury population. Indomethacin may have a role inthe management of raised ICP associated with hyperaemia aftersevere head injury. We recommend however that it should onlybe used with monitoring of both Sj_O2 and MCAV.     

重度吸入性损伤的救治体会

目的总结30例重度吸入性损伤的治疗经验与失败教训。方法从治愈与死亡病例中回顾与总结重度吸入性损伤的治疗经验。如:诊断明确即行气管切开、吸氧治疗,气道冲洗清除气道分泌物;皮质激素短期用于肺水肿或严重支气管痉挛时,鼓励病人咳嗽、深呼吸、翻身拍背、体位引流等。结果本组30例中治愈14例,治愈率为46.6%,死亡16例.病死率为53.3%。结论抓早、抓好各项治疗措施,重视并发症的防治,可提高此类病人的治愈率。     

重度吸入性损伤的救治体会

目的　总结３０ 例重度吸入性损伤的治疗经验与失败教训。方法　从治愈与死亡病例中回顾与总结重度吸入性损伤的治疗经验。如：诊断明确即行气管切开、吸氧治疗,气道冲洗清除气道分泌物;皮质激素短期用于肺水肿或严重支气管痉挛时,鼓励病人咳嗽、深呼吸、翻身拍背、体位引流等。结果　本组３０ 例中治愈１４ 例,治愈率为４６－６％ ,死亡１６ 例,病死率为５３－３％ 。结论抓早、抓好各项治疗措施,重视并发症的防治,可提高此类病人的治愈率     

重度吸入性损伤的救治体会

目的 总结３０例重度吸入性损伤的治疗经验与失败教训。方法 从治愈与死亡病例中回顾与总结重度吸入性损伤的治疗经验。如：诊断明确即行气管切开、吸氧治疗,气道冲洗清除气道分泌物;皮质激素短期用于肺水肿或严重支气管痉挛时,鼓励病人咳嗽、深呼吸、翻身拍背、体位引流等。结果 本组３０例中治愈１４例,治愈率为４６．６％,死亡１６例,病死率为５３．３％。结论 抓早１抓好各项治疗措施,重视并发症的防治,可提高此类病     

The management of acute severe head injury

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Critical care management of severe head injury

Severe traumatic brain injury (TBI) is a significant cause of morbidity and mortality. The intensive care management of TBI requires a coordinated and comprehensive approach to treatment, including strategies to prevent secondary brain injury by avoidance of systemic physiological disturbances, such as hypotension, hypoxaemia, hypoglycaemia, hyperglycaemia and hyperthermia, and maintenance of adequate cerebral perfusion and oxygenation. There have been marked improvements in the management of patients with severe TBI over the last two decades, and treatment advances in the pre-hospital setting and emergency department have recently extended into the intensive care unit. The management of head injury has undergone extensive revision as evidence accumulates that established practices are not as effective or innocuous as previously believed. Management protocols have evolved with international consensus, providing guidelines that assist clinicians in delivering optimal care. Improved diagnostic and monitoring modalities are improving the understanding of the pathophysiology of head injury and allowing the delivery of individualised therapy.     

Althesin in the management of head injuries: a preliminary report

The aggressive treatment of major craniocerebral trauma has received recent attention. Barbiturate administration has been beneficial in some cases of sustained, uncontrolled intracranial hypertension. One major disadvantage of pentobarbital narcosis is the long half-life of the drug (15 to 48 hours). We have used Althesin, an intravenous steroid anesthetic (alfaxalone and alfadolone acetate; Glaxo Laboratories Ltd., Greenford, Middlesex, England), in eight seriously head-injured patients. Althesin combines the theoretical advantages of pentobarbital in the management of head trauma with almost immediate reversibility (serum half-life, 1.6 minutes). Raised intracranial pressure and clinical outcome seem to be influenced favorably and the side effects are negligible when the drug is administered by continuous intravenous infusion over several days. Further study of this compound in the management of head trauma seems warranted.     

High dose glucocorticoids in the management of severe head injury

Eighty-eight patients with a Glasgow coma score of 8 or less 6 hours after nonpenetrating head trauma were given either high dose methylprednisolone sodium succinate (30 mg/kg q6h X2, then 250 mg q6h X6, then tapering over 8 days), low dose methylprednisolone (1.5 mg/kg q6h X2, then 25 mg q6h X6, then tapering over 8 days), or placebo. Standard care including the removal of traumatic hematomas, assisted ventilation, and intracranial pressure monitoring and control was carried out. Follow-up assessments were performed on all surviving patients at 6 months and were graded according to the Glascow outcome scale. No statistically significant difference in outcome was seen between the low dose group and the placebo group. The high dose group experienced a mortality of 39% as compared to a 52% mortality in the low dose and placebo groups (P less than 0.05). Mortality differences were most marked in patients less than 40 years old, with the high dose group experiencing a mortality of 6% as compared to a 43% mortality for the low dose and placebo groups (P less than 0.05). For patients under 50 years old, the incidence of recovery of speech was 62% compared to 36% in the low dose and placebo groups (P less than 0.5). The increased survival in those treated with high dose corticoids, however, was associated with an increase in the poorer outcome categories.     

Relationship of acute CBF and ICP findings to neuropsychological outcome in severe head injury

Neuropsychological outcome within 1 year after severe head injury was examined in 42 conscious survivors and correlated with acute measurements of cerebral blood flow (CBF) and intracranial pressure (ICP). During acute coma, CBF was elevated in 23 patients, indicating hyperemia, and was reduced in the remaining 19 cases. Intracranial hypertension (ICP 20 mm Hg or greater) was present acutely in 15 patients and absent in 27. Occurrences of hyperemia and intracranial hypertension were significantly related. During chronic recovery, neuropsychological dysfunction was found in all cases. However, patients with hyperemia revealed greater impairment of overall intellectual and memory functions than did those with reduced flow, while patients with intracranial hypertension showed greater memory deficit than did those without ICP elevations. The results suggest that early pathophysiological events can influence subsequent neuropsychological outcome, and that chronic recovery is not homogeneous in young severely head-injured adults.     

EBIC-Guidelines for management of severe head injury in adults

Summary Guidelines for the management of severe head injury in adults as evolved by the European Brain Injury Consortium are presented and discussed. The importance of preventing and treating secondary insults is emphasized and the principles on which treatment is based are reviewed. Guidelines presented are of a pragmatic nature, based on consensus and expert opinion, covering the treatment from accident site to intensive care unit. Specific aspects pertaining to the conduct of clinical trials in head injury are highlighted. The adopted approach is further discussed in relation to other approaches to the development of guidelines, such as evidence based analysis.     

Suppression of cellular immune activity following severe head injury

Infection is a major cause of morbidity following multiple traumatic and head injury. Although immunosuppression has been demonstrated after multiple traumatic injury, the effects of head injury on immune function have not been thoroughly investigated. In a prospective study of 10 severely head-injured patients, in vitro and in vivo parameters of cellular immune activity were assessed. In vitro measurements of lymphocyte surface antigen expression following mitogen stimulation were made serially over a 3-week period in 10 patients with severe head injury. The control group consisted of 20 healthy subjects. Phenotyping of peripheral blood lymphocytes (PBLs) was performed following incubation with and without mitogens. Phenotypes were determined by flow cytometry using monoclonal antibodies (MABs) to T lymphocyte subsets and the alpha subunit of interleukin 2 (IL-2) receptors. In vivo cellular immune function was determined by measuring patient responses to delayed-type hypersensitivity (DTH) skin testing within 24 h of injury. When head-injured patients were compared to controls, PBLs incubated in the presence of phytohemagglutinin (PHA) demonstrated a decrease in cells marking as T cells (p = 0.005), helper-inducer T cells (p = 0.001), and in the number of IL-2 receptor-bearing cells (p = 0.001). The functional ability of these lymphocyte subpopulations to proliferate in the presence of PHA was significantly suppressed within 24 h of injury and normalized within 3 weeks of injury. DTH skin testing to Candida, mumps, trichophyton, and PPD antigens was performed within 24 h of injury and resulted in anergic responses in all 10 patients when measured at 24, 48, and 72 h following administration. The overall infection rate was 60%, with the majority of infections occurring within the first 4 days following injury. The results of this study indicate that severe head injury results in suppression of cellular immune function with a corresponding high rate of infection. The possible significance of the decrease in the percentage of helper-inducer T cells and in the number of cells bearing IL-2 receptors following mitogen stimulation is discussed.     

Reduction in mortality from severe head injury following introduction of a protocol for intensive care management

Editor—Clayton and colleagues report a relative risk reductionin intensive care mortality of nearly 30% from severe head injurywith the introduction of protocol-driven management to theirhospital.¹ Adequate cerebral perfusion pressure is the primarygoal of     

Reduction in mortality from severe head injury following introduction of a protocol for intensive care management

Background. To determine the effect of an intensive care managementprotocol on the intensive care unit (ICU) and hospital mortalityof severely head-injured patients, we designed a longitudinalobservational study of all patients admitted with a head injurybetween 1992 and 2000. Methods. A computerized patient database was used to identifyall patients with severe head injury admitted to the ICU atFrenchay Hospital, Bristol, UK: a tertiary referral centre forthe clinical neurosciences. We compared the ICU and hospitalmortality and length of stay in patients before and after implementationof a protocol for their ICU management in 1997. Results. Implementation of the protocol was associated witha significant reduction in ICU mortality from 19.95% to 13.5%(odds ratio 0.47; 95% CI 0.29–0.75), and in hospital mortalityfrom 24.55% to 20.8% (odds ratio 0.48; 95% CI 0.31–0.74).This was achieved despite a significant increase in the medianAPACHE II score (14 vs 18) of patients admitted after implementationof the protocol. The median ICU and hospital length of stayremained constant over the study period. Conclusions. The introduction of an evidence-based protocolto guide the ICU management of patients with severe head injuryhas been associated with a significant reduction in both ICUand hospital mortality.      

Useful ICP monitoring with subarachnoid catheter method in severe head injuries

ICP in 233 patients with severe head injuries was monitored utilizing a subarachnoid catheter technique. The relationships between initial ICP and GCS, between initial ICP and GOS, between maximal ICP and GCS, and between maximal ICP and GOS were examined statistically. The correlation was significant in each case, but particularly so between maximal ICP and GOS. Thus morbidity and mortality may be dependent upon maximal ICP. Catheterization of the subarachnoid space presents little difficulty using a Tuohy needle for epidural anesthesia as an introducer. Though the catheter is very fine (1.0 mm in outer diameter), failure of waveform occurred in only 2.1% of all patients. The procedure can be easily performed at the bedside, is safe, inexpensive, and useful for the management of severe head injuries. Meningitis was recognized in 4.7% of all patients.