Severe traumatic brain injury

High-Dose Barbiturates for Refractory Intracranial Hypertension in Children With Severe Traumatic Brain Injury

Authors: Mellion SA, Bennett KS, Ellsworth GL, Moore K, Riva-Cambrin J, Metzger RR, Bratton SL.

OBJECTIVES:: To evaluate high-dose barbiturates as a second-tier therapy for pediatric refractory intracranial hypertension complicating severe traumatic brain injury. DESIGN:: This is a retrospective cohort study of children with refractory intracranial hypertension treated with high-dose barbiturates. SETTING:: A single center level I pediatric trauma from 2001 to 2010. PATIENTS:: Thirty-six children with refractory intracranial hypertension defined as intracranial pressure greater than 20 mm Hg despite standard management treated with high-dose barbiturates after severe traumatic brain injury. INTERVENTIONS:: High-dose barbiturates were administered for refractory intracranial hypertension for a minimum duration of 6 hrs and monitored by continuous electroencephalography. MEASUREMENTS AND MAIN RESULTS:: Exposure was control of refractory intracranial hypertension defined as > 20 mm Hg within 6 hrs after starting barbiturates. Pediatric cerebral performance category scores at hospital discharge and at 3 months (or longer) follow-up were the primary outcomes. Ten (28%) of 36 patients had control of refractory intracranial hypertension. Neither demographic nor injury characteristics were associated with refractory intracranial hypertension control. Children who responded received barbiturates significantly later after injury (76 vs. 29 median hours). Overall, 14 children died, 13 without control of intracranial pressure. Survival was more common in those who responded compared with those who did not respond to high-dose barbiturates, although this did not reach statistical significance (relative risk of death 0.2; 95% confidence interval; ). Of the 22 survivors, 19 had an acceptable survival (pediatric cerebral performance category less than 3) at 3 months or longer after injury; however, only three returned to normal function. Among survivors, control of refractory intracranial hypertension was associated with significantly better pediatric cerebral performance category scores and over two-fold likelihood of acceptable long-term outcome (relative risk 2.3; 95% confidence interval ) compared with uncontrolled refractory intracranial hypertension despite high-dose barbiturates. CONCLUSIONS:: Addition of high-dose barbiturates achieved control of refractory intracranial hypertension in almost 30% of treated children. Control of refractory intracranial hypertension was associated with increased likelihood of an acceptable long-term outcome.

Physiological monitoring of the severe traumatic brain injury patient in the intensive care unit

Authors: Le Roux P.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Despite encouraging animal research, pharmacological agents and neuroprotectants have disappointed in the clinical environment. Current TBI management therefore is directed towards identification, prevention, and treatment of secondary cerebral insults that are known to exacerbate outcome after injury. This strategy is based on a variety of monitoring techniques that include the neurological examination, imaging, laboratory analysis, and physiological monitoring of the brain and other organ systems used to guide therapeutic interventions. Recent clinical series suggest that TBI management informed by multimodality monitoring is associated with improved patient outcome, in part because care is provided in a patient-specific manner. In this review we discuss physiological monitoring of the brain after TBI and the emerging field of neurocritical care bioinformatics.

Increased intracranial pressure is associated with the development of acute lung injury following severe traumatic brain injury

Authors: Lou M, Chen X, Wang K, Xue Y, Cui D, Xue F.

OBJECTIVE: This study investigated the relationship among intracranial pressure (ICP), the development of acute lung injury (ALI) and systemic inflammatory response syndrome (SIRS) following a severe traumatic brain injury (TBI).
METHODS: Post-traumatic ICP was continuously monitored for the first week following injury in a series of consecutive patients with isolated severe TBI. The initial ICP and the duration of intracranial hypertension (ICH) were calculated. The risk factors associated with the development of ALI and SIRS were evaluated.
RESULTS: Of the 86 patients enrolled, 22 patients developed ALI and 52 patients developed SIRS during the observation period. The patients with ALI presented with a significantly higher initial ICP (31.3±7.8mmHg vs. 23.0±8.8mmHg, p<0.001) and a longer duration of ICH (16.8±6.5h vs. 11.9±6.0h, p=0.002) than those without ALI. The incidence of both ALI and SIRS increased with increasing initial ICP, and the presence of SIRS was associated with a fourfold increase in the risk of developing ALI (odds ratio , 4.0; 95% confidence interval , 1.2-13.0).
CONCLUSIONS: Increased ICP is associated with increased risks of developing ALI and SIRS following severe TBI. Future studies designed to verify the causative relationship between increased ICP and the systemic responses are warranted.
Copyright © 2012 Elsevier B.V. All rights reserved.

The spectrum captured: a methodological approach to studying incidence and outcomes of traumatic brain injury on a population level

Authors: Theadom A, Barker-Collo S, Feigin VL, Starkey NJ, Jones K, Jones A, Ameratunga S, Barber PA; BIONIC Research Group.

OBJECTIVE: Drawing on the experience of conducting the Brain Injury Incidence and Outcomes New Zealand in the Community study, this article aims to identify the issues arising from the implementation of proposed guidelines for population-based studies of incidence and outcomes in traumatic brain injury (TBI).
STUDY DESIGN AND SETTING: All new cases of TBI (all ages and severities) were ascertained over a 1-year period, using overlapping prospective and retrospective sources of case ascertainment in New Zealand. All eligible TBI cases were invited to participate in a comprehensive assessment at baseline and at 1-month follow-up.
RESULTS: Our experience to date has revealed the feasibility of case ascertainment methods. Consultation with community health services and professionals resulted in feasible referral pathways to support the identification of TBI cases. 'Hot pursuit' methods of recruitment were essential to ensure complete case ascertainment for this population with few additional cases of TBI identified through cross-checks.
CONCLUSION: This review of proposed guidelines in relation to practical study methodology provides a framework for future comparable population-based epidemiological studies of TBI incidence and outcomes in developed countries.

Controversies in the management of adults with severe traumatic brain injury

Author: Blissitt PA.

Despite progress in the management of adults with severe traumatic brain injury, several controversies persist. Among the unresolved issues of greatest concern to neurocritical care clinicians and scientists are the following: (1) the best use of technological advances and the data obtained from multimodality monitoring; (2) the use of mannitol and hypertonic saline in the management of increased intracranial pressure; (3) the use of decompressive craniectomy and barbiturate coma in refractory increased intracranial pressure; (4) therapeutic hypothermia as a neuroprotectant; (5) anemia and the role of blood transfusion; and (6) venous thromboembolism prophylaxis in severe traumatic brain injury. Each of these strategies for managing severe traumatic brain injury, including the postulated mechanism(s) of action and beneficial effects of each intervention, adverse effects, the state of the science, and critical care nursing implications, is discussed.

US Estimates of Hospitalized Children With Severe Traumatic Brain Injury: Implications for Clinical Trials

Authors: Stanley RM, Bonsu BK, Zhao W, Ehrlich PF, Rogers AJ, Xiang H.

OBJECTIVES: To estimate sample sizes available for clinical trials of severe traumatic brain injury (TBI) in children, we described the patient demographics and hospital characteristics associated with children hospitalized with severe TBI in the United States.

METHODS: We analyzed the 2006 Kids' Inpatient Database. Severe TBI hospitalizations were defined as children discharged with TBI who required mechanical ventilation or intubation. Types of high-volume severe TBI hospitals were categorized based on the numbers of discharged patients with severe TBI in 2006. National estimates of demographics and hospital characteristics were calculated for pediatric severe TBI. Simulation analyses were performed to assess the potential number of severe TBI cases from randomly selected hospitals for inclusion in future clinical trials.

RESULTS: The majority of children with severe TBI were discharged from either a children's unit in general hospitals (41%) or a nonchildren's hospital (34%). Less than 5% of all hospitals were high-volume TBI hospitals, which discharged >78% of severe TBI cases and were more likely to be a children's unit in a general hospital or a children's hospital. Simulation analyses indicate that there is a saturation point after which the benefit of adding additional recruitment sites decreases significantly.

CONCLUSIONS: Children with severe TBI are infrequent at any one hospital in the United States, and few hospitals treat large numbers of children with severe TBI. To effectively plan trials of therapies for severe TBI, much attention has to be paid to selecting the right types of centers to maximize enrollment efficiency.


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