Specialist neurocritical care and outcome from head injury (original) (raw)
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Critical Care Medicine, 2005
Introduction: Uncontrolled intracranial hypertension and low cerebral perfusion pressure (CPP) after severe head injury is associated with case fatality. However, there is no sound evidence that monitoring of intracranial pressure (ICP) and targeted management of CPP improves functional outcome, despite widespread recommendation by experts in the field. Methods: We conducted a follow-up study of severely head-injured adults in two trauma centers in The Netherlands. Of 685 patients admitted from 1996 to 2001, we analyzed 333 patients who were alive and in coma 24h after injury. Allocation to either trauma center was solely based on the site of the accident. In center A (supportive intensive care), ICP was not monitored, mean arterial pressure was maintained at approximately 90 mm Hg, and therapeutic interventions were based on specific clinical observations and CT findings. In center B (ICP/CPP targeted intensive care), protocol-driven management was aimed to maintain ICP < 20 mm Hg and CPP > 70 mm Hg. The extended Glasgow Outcome Scale (GOSe) was prospectively assessed. Ordinal logistic regression analysis was used to adjust for potential confounders. Results: Demographic and injury severity characteristics at baseline were well balanced between the centers. Table 1 shows functional outcome after a median follow-up of 47 (25th-75th percentile: 36-67) months. In-hospital mortality was 41 (34%) and 69 (33%) in centers A and B, respectively (p=0.87). The odds-ratio for a more favorable functional outcome following ICP/CPP targeted therapy was 0.95 (95% CI: 0.62-1.44). This result remained after adjustment for age, motor score, pupil reactivity, CT scan category, injury cause, and intracranial surgery. Sedatives, vasopressors, mannitol, and barbiturates were much more frequently used in center B (table 2). The median number of days on ventilator support in survivors was 5 (2-9) in center A, versus 12 (7-19) in center B (p<0.01). Conclusion: ICP/CPP targeted intensive care resulted in prolonged mechanical ventilation and increased levels of therapy intensity, without evidence for improved outcome in comatose patients who survived beyond 24h following severe head injury. These findings suggest that it is acceptable to withhold ICP monitoring in the setting of a randomized controlled trial of ICP/CPP targeted treatment.
Annals of Emergency Medicine, 1983
Objective: Intracranial hypertension after severe head injury is associated with case fatality, but there is no sound evidence that monitoring of intracranial pressure (ICP) and targeted management of cerebral perfusion pressure (CPP) improve outcome, despite widespread recommendation by experts in the field. The purpose was to determine the effect of ICP/CPP-targeted intensive care on functional outcome and therapy intensity levels after severe head injury.
Neurocritical Care, 2006
To investigate the relationships between intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome after traumatic brain injury. A retrospective analysis of prospectively recorded data from 429 patients after head injury requiring intensive treatment on the Neuroscience Intensive Annex and the Neuro Critical Care Unit, Cambridge, UK. ICP, CPP, and arterial blood pressure (ABP) were continuously recorded. Mean values of pressures were compared to outcome assessed at 6 months after injury (using the Glasgow Outcome Scale). The mortality rate was greater in those having mean ICP greater than 20 mmHg (17% below versus 47% above; p &amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). The mortality rate was dramatically increased for CPP below 55 mmHg (81% below versus 23% above; p &amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). For values of CPP greater than 95 mmHg, favorable outcome was less frequent (50% below versus 28% above; p &amp;amp;amp;amp;amp;amp;amp;lt; 0.033). The rate of severe disability showed the tendency to increase with CPP ( r = 0.87; p = 0.02), suggesting that a higher CPP does not help in achieving favorable outcomes. ICP was greater in those who died in comparison to those who survived (27 +/- 19 mmHg versus 16 +/- 6 mmHg; p &amp;amp;amp;amp;amp;amp;amp;lt; 0.10 - 7), and CPP was lower (68 +/- 21 versus 76 +/- 10 mmHg; p &amp;amp;amp;amp;amp;amp;amp;lt; 0.0002). There was no difference between mean ICP and CPP in good/moderate and severe disability outcome groups. High ICP is strongly associated with fatal outcome. Excessive CPP seems to reduce the probability of achieving a favorable outcome following head trauma.
ICP threshold in CPP management of severe head injury patients
Surgical Neurology, 2004
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 Ն20 mm Hg or Ն25 mm Hg.
Journal of Neurosurgical Anesthesiology, 1999
Objectives-To assess the eVectiveness of interventions routinely used in the intensive care management of severe head injury, specifically, the eVectiveness of hyperventilation, mannitol, CSF drainage, barbiturates, and corticosteroids. Methods-Systematic review of all unconfounded randomised trials, published or unpublished, that were available by August 1996. Results-None of the interventions has been reliably shown to reduce death or disability after severe head injury. One trial of hyperventilation was identified of 77 participants. The relative risk for death was 0.73 (95% confidence interval (95% CI) 0.36-1.49), and for death or disability it was 1.14 (95% CI 0.82-1.58). One trial of mannitol was identified of 41 participants. The relative risk for death was 1.75 (95% CI 0.48-6.38), no data were available for disability. No randomised trials of CSF drainage were identified. Two randomised trials of barbiturate therapy were identified, including 126 participants. The pooled relative risk for death was 1.12 (95% CI 0.81-1.54). Disability data were available for one trial. The relative risk for death or disability was 0.96 (95% CI 0.62-1.49). Thirteen randomised trials of corticosteroids were identified, comprising 2073 participants. The pooled relative risk for death was 0.95 (0.84 to 1.07) and for death or disability it was 1.01 (95% CI 0.91 to 1.11). On the basis of the currently available randomised evidence, for every intervention studied it is impossible to refute either a moderate increase or a moderate decrease in the risk of death or disability. Conclusion-Existing trials have been too small to support or refute the existence of a real benefit from using hyperventilation, mannitol, CSF drainage, barbiturates, or corticosteroids. Further large scale randomised trials of these interventions are required. (J Neurol Neurosurg Psychiatry 1998;65:729-733) Keywords: head injuries; systematic review; metaanalysis; randomised controlled trials World wide, several million people, mostly children and young adults, are treated each
Journal of Neurology, Neurosurgery & Psychiatry, 1998
Objectives-To assess the eVectiveness of interventions routinely used in the intensive care management of severe head injury, specifically, the eVectiveness of hyperventilation, mannitol, CSF drainage, barbiturates, and corticosteroids. Methods-Systematic review of all unconfounded randomised trials, published or unpublished, that were available by August 1996. Results-None of the interventions has been reliably shown to reduce death or disability after severe head injury. One trial of hyperventilation was identified of 77 participants. The relative risk for death was 0.73 (95% confidence interval (95% CI) 0.36-1.49), and for death or disability it was 1.14 (95% CI 0.82-1.58). One trial of mannitol was identified of 41 participants. The relative risk for death was 1.75 (95% CI 0.48-6.38), no data were available for disability. No randomised trials of CSF drainage were identified. Two randomised trials of barbiturate therapy were identified, including 126 participants. The pooled relative risk for death was 1.12 (95% CI 0.81-1.54). Disability data were available for one trial. The relative risk for death or disability was 0.96 (95% CI 0.62-1.49). Thirteen randomised trials of corticosteroids were identified, comprising 2073 participants. The pooled relative risk for death was 0.95 (0.84 to 1.07) and for death or disability it was 1.01 (95% CI 0.91 to 1.11). On the basis of the currently available randomised evidence, for every intervention studied it is impossible to refute either a moderate increase or a moderate decrease in the risk of death or disability. Conclusion-Existing trials have been too small to support or refute the existence of a real benefit from using hyperventilation, mannitol, CSF drainage, barbiturates, or corticosteroids. Further large scale randomised trials of these interventions are required. (J Neurol Neurosurg Psychiatry 1998;65:729-733) Keywords: head injuries; systematic review; metaanalysis; randomised controlled trials World wide, several million people, mostly children and young adults, are treated each
Critical care management of severe head injury
Anaesthesia & Intensive Care Medicine, 2014
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.
Management of patients with head injury
The Lancet, 2008
Over the past 25 years, many guidelines have been developed for the management of head injury, most of which have been aimed at the treatment of patients with severe head injury and in a coma. 1–3 This Viewpoint aims to establish an accurate method of identifying patients who have sustained a head injury (often apparently minor) and who need further inpatient observation and treatment compared with those who can be safely discharged, but it does not address the issue of guidelines for the treatment of severely injured patients. ...