scholarly journals Early enteral nutrition in patients with severe traumatic brain injury: a propensity score–matched analysis using a nationwide inpatient database in Japan

2019 ◽  
Vol 111 (2) ◽  
pp. 378-384 ◽  
Author(s):  
Hiroyuki Ohbe ◽  
Taisuke Jo ◽  
Hiroki Matsui ◽  
Kiyohide Fushimi ◽  
Hideo Yasunaga
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Propensity Score ◽  
Enteral Nutrition ◽  
Hospital Mortality ◽  
Nosocomial Pneumonia ◽  
Severe Traumatic Brain Injury ◽  
Scale Scores ◽  
Severe Tbi ◽  
Inpatient Database

ABSTRACT Background Whether enteral nutrition (EN) should be administered early in severe traumatic brain injury (TBI) patients has not been fully addressed. Objective The present study aimed to evaluate whether early EN can reduce mortality or nosocomial pneumonia among severe TBI patients. Methods Using the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2017 linked with the Survey for Medical Institutions, we identified patients admitted for intracranial injury with Japan Coma Scale scores ≥30 (corresponding to Glasgow Coma Scale scores ≤8) at admission. We designated patients who started EN within 2 d of admission as the early EN group, and those who started EN at 3–5 d after admission as the delayed EN group. The primary outcome was in-hospital mortality. The secondary outcome was nosocomial pneumonia. Propensity score–matched analyses were performed to compare the outcomes between the 2 groups. Results We identified 3080 eligible patients during the 36-mo study period, comprising 1100 (36%) in the early EN group and 1980 (64%) in the delayed EN group. After propensity score matching, there was no significant difference in in-hospital mortality (difference: −0.3%; 95% CI: −3.7%, 3.1%) between the 2 groups. The proportion of nosocomial pneumonia was significantly lower in the early EN group than in the delayed EN group (difference: −3.2%; 95% CI: −5.9%, −0.4%). Conclusions Early EN may not reduce mortality, but may reduce nosocomial pneumonia in patients with severe TBI.

scholarly journals Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study

BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e047305
Author(s):  
Susan Alcock ◽  
Divjeet Batoo ◽  
Sudharsana Rao Ande ◽  
Rob Grierson ◽  
Marco Essig ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cohort Study ◽  
Brain Injury ◽  
Early Diagnosis ◽  
Hospital Mortality ◽  
Brain Death ◽  
Severe Traumatic Brain Injury ◽  
Health Research ◽  
Ct Perfusion ◽  
Severe Tbi

IntroductionSevere traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist to determine brain death; however, most are difficult to elicit in the acute setting in patients with severe TBI. Having a definitive assessment tool would help predict early in-hospital mortality in this population. CT perfusion (CTP) has shown promise diagnosing early in-hospital mortality in patients with severe TBI and other populations. The purpose of this study is to validate admission CTP features of brain death relative to the clinical examination outcome for characterizing early in-hospital mortality in patients with severe TBI.Methods and analysisThe Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients.Ethics and disseminationThis study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study.Trial registration numberNCT04318665

scholarly journals Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index

2021 ◽  
Author(s):  
Maximilian Peter Forssten ◽  
Gary Alan Bass ◽  
Kai-Michael Scheufler ◽  
Ahmad Mohammad Ismail ◽  
Yang Cao ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Severe Traumatic Brain Injury ◽  
Mortality Risk ◽  
Risk Index ◽  
Cardiac Risk ◽  
Increased Risk ◽  
Severe Tbi

Abstract Purpose Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. Methods All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. Results 259,399 patients met the study’s inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01–1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05–1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11–1.90), p = 0.006], compared to RCRI 0. Conclusion An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

scholarly journals Use of Vasopressors Increases the Risk of Mortality in Severe Traumatic Brain Injury: A Nationwide Retrospective Cohort Study in Japan

2021 ◽  
Author(s):  
Sanae Hosomi ◽  
Tomotaka Sobue ◽  
Tetsuhisa Kitamura ◽  
Atsushi Hirayama ◽  
Hiroshi Ogura ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Emergency Department ◽  
Cohort Study ◽  
Brain Injury ◽  
Propensity Score ◽  
Hospital Discharge ◽  
Severe Traumatic Brain Injury ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Severe Tbi

Abstract Background: Pharmacological elevation of blood pressure is frequently incorporated in severe traumatic brain injury (TBI) management algorithms. However, there is limited evidence on prevalent clinical practices regarding resuscitation for severe TBI using vasopressors. We conducted a nationwide retrospective cohort study to determine the association between the use of vasopressors and mortality following discharge from hospital in patients with severe TBI, and to determine whether the use of vasopressors affects emergency department mortality or the occurrence of cognitive dysfunction.Methods: Data were collected between January 2004 and December 2018 by the Japanese Trauma Data Bank, which includes data from 272 emergency hospitals in Japan. Adults aged ≥ 16 years with severe TBI, without other major injuries, were examined. A severe TBI was defined based on the Abbreviated Injury Scale code and a Glasgow Coma Scale score of 3–8 on admission. Multivariable and propensity score matching analyses were performed. Statistical significance was assessed using a 95% CI.Results: In total, 10,284 patients were eligible for analysis, with 650 patients (6.32%) included in the vasopressor group and 9,634 patients (93.68%) included in the non-vasopressor group. The proportion of deaths on hospital discharge was higher in the vasopressor group than in the non-vasopressor group (81.69% [531/650] vs. 40.21% [3,874/9,634]). This finding was confirmed by multivariable logistic regression analysis (adjusted odds ratio [OR], 5.71; 95% confidence interval [CI]: 4.56–7.16). Regarding propensity score-matched patients, the proportion of deaths on hospital discharge remained higher in the vasopressor group than in the non-vasopressor group (81.66% [530/649] vs. 50.69% [329/649]) (OR, 4.33; 95% CI: 3.37–5.57). The vasopressor group had a higher emergency department mortality rate than the non-vasopressor group (8.01% [52/649] vs. 2.77% [18/649]) (OR, 3.05; 95% CI: 1.77–5.28). There was no reduction in complications of cognitive disorders in the vasopressor group (5.39% [35/649] vs. 5.55% [36/649]) (OR, 0.97; 95% CI: 0.60–1.57).Conclusions: In this population, the use of vasopressors for severe TBI was associated with higher mortality on hospital discharge. Our results suggest that vasopressors should be avoided in most cases of severe TBI.

scholarly journals Modulated Neuroprotection in Unresponsive Wakefulness Syndrome after Severe Traumatic Brain Injury

2021 ◽  
Vol 11 (8) ◽  
pp. 1044
Author(s):  
Cristina Daia ◽  
Cristian Scheau ◽  
Aura Spinu ◽  
Ioana Andone ◽  
Cristina Popescu ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Severe Traumatic Brain Injury ◽  
Functional Independence ◽  
Unresponsive Wakefulness Syndrome ◽  
Coma Scale ◽  
Severe Tbi ◽  
Neuroprotective Treatment ◽  
Gcs Score

Background: We aimed to assess the effects of modulated neuroprotection with intermittent administration in patients with unresponsive wakefulness syndrome (UWS) after severe traumatic brain injury (TBI). Methods: Retrospective analysis of 60 patients divided into two groups, with and without neuroprotective treatment with Actovegin, Cerebrolysin, pyritinol, L-phosphothreonine, L-glutamine, hydroxocobalamin, alpha-lipoic acid, carotene, DL-α-tocopherol, ascorbic acid, thiamine, pyridoxine, cyanocobalamin, Q 10 coenzyme, and L-carnitine alongside standard treatment. Main outcome measures: Glasgow Coma Scale (GCS) after TBI, Extended Glasgow Coma Scale (GOS E), Disability Rankin Scale (DRS), Functional Independence Measurement (FIM), and Montreal Cognitive Assessment (MOCA), all assessed at 1, 3, 6, 12, and 24 months after TBI. Results: Patients receiving neuroprotective treatment recovered more rapidly from UWS than controls (p = 0.007) passing through a state of minimal consciousness and gradually progressing until the final evaluation (p = 0.000), towards a high cognitive level MOCA = 22 ± 6 points, upper moderate disability GOS-E = 6 ± 1, DRS = 6 ± 4, and an assisted gait, FIM =101 ± 25. The improvement in cognitive and physical functioning was strongly correlated with lower UWS duration (−0.8532) and higher GCS score (0.9803). Conclusion: Modulated long-term neuroprotection may be the therapeutic key for patients to overcome UWS after severe TBI.

Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

2017 ◽  
Vol 32 (5) ◽  
pp. 692-704 ◽  
Author(s):  
Camille Chesnel ◽  
Claire Jourdan ◽  
Eleonore Bayen ◽  
Idir Ghout ◽  
Emmanuelle Darnoux ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Significant Relationship ◽  
Injury Severity ◽  
Chronic Phase ◽  
Functional Independence ◽  
Severe Tbi

Objective: To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness. Design/Setting/Subjects: This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study). Intervention/Main measures: Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life. Results: A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)). Conclusion: Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury

2008 ◽  
Vol 109 (4) ◽  
pp. 678-684 ◽  
Author(s):  
Anne Vik ◽  
Torbjørn Nag ◽  
Oddrun Anita Fredriksli ◽  
Toril Skandsen ◽  
Kent Gøran Moen ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Hypertension ◽  
Scale Score ◽  
Severe Traumatic Brain Injury ◽  
Injury Severity ◽  
Area Under The Curve ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Scale Scores

Object It has recently been suggested that the degree of intracranial pressure (ICP) above the treatment goal can be estimated by the area under the curve (AUC) of ICP versus time in patients with severe traumatic brain injury (TBI). The objective of this study was to determine whether the calculated “ICP dose”—the ICP AUC—is related to mortality rate, outcome, and Marshall CT classification. Methods Of 135 patients (age range 1–82 years) with severe TBI treated during a 5-year period at the authors' institution, 113 patients underwent ICP monitoring (84%). Ninety-three patients with a monitoring time > 24 hours were included for analysis of ICP AUC calculated using the trapezoidal method. Computed tomography scans were assessed according to the Marshall TBI classification. Patients with Glasgow Outcome Scale scores at 6 months and > 3 years were separated into 2 groups based on outcome. Results Sixty patients (65%) had ICP values > 20 mm Hg, and 12 (13%) developed severe intracranial hypertension and died secondary to herniation. A multiple regression analysis adjusting for Glasgow Coma Scale score, age, pupillary abnormalities and Injury Severity Scale score demonstrated that the ICP AUC was a significant predictor of poor outcome at 6 months (p = 0.034) and of death (p = 0.035). However, it did not predict long-term outcome (p = 0.157). The ICP AUC was significantly higher in patients with Marshall head injury Categories 3 and 4 (24 patients) than in those with Category 2 (23 patients, p = 0.025) and Category 5 (46 patients, p = 0.021) TBIs using the worst CT scan obtained. Conclusions The authors found a significant relationship between the dose of ICP, the worst Marshall CT score, and patient outcome, suggesting that the AUC method may be useful in refining and improving the treatment of ICP in patients with TBI.

scholarly journals Critical Update on the Third Edition of the Guidelines for Managing Severe Traumatic Brain Injury in Children

2020 ◽  
Vol 29 (1) ◽  
pp. e13-e18
Author(s):  
Karin Reuter-Rice ◽  
Elise Christoferson
Keyword(s):  
Traumatic Brain Injury ◽  
Critical Care ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Current Evidence ◽  
Care Providers ◽  
The Third ◽  
Guideline Document ◽  
Severe Tbi ◽  
Pediatric Tbi

Background Severe traumatic brain injury (TBI) is associated with high rates of death and disability. As a result, the revised guidelines for the management of pediatric severe TBI address some of the previous gaps in pediatric TBI evidence and management strategies targeted to promote overall health outcomes. Objectives To provide highlights of the most important updates featured in the third edition of the guidelines for the management of pediatric severe TBI. These highlights can help critical care providers apply the most current and appropriate therapies for children with severe TBI. Methods and Results After a brief overview of the process behind identifying the evidence to support the third edition guidelines, both relevant and new recommendations from the guidelines are outlined to provide critical care providers with the most current management approaches needed for children with severe TBI. Recommendations for neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, ventilation therapies, temperature control/hypothermia, nutrition, and corticosteroids are provided. In addition, the complete guideline document and its accompanying algorithm for recommended therapies are available electronically and are referenced within this article. Conclusions The evidence base for treating pediatric TBI is increasing and provides the basis for high-quality care. This article provides critical care providers with a quick reference to the current evidence when caring for a child with a severe TBI. In addition, it provides direct access links to the comprehensive guideline document and algorithms developed to support critical care providers.

scholarly journals Use of Vasopressors Increases the Risk of Mortality in Severe Traumatic Brain Injury: A Nationwide Retrospective Cohort Study in Japan

2021 ◽  
Author(s):  
Sanae Hosomi ◽  
Tomotaka Sobue ◽  
Tetsuhisa Kitamura ◽  
Atsushi Hirayama ◽  
Hiroshi Ogura ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Emergency Department ◽  
Cohort Study ◽  
Brain Injury ◽  
Propensity Score ◽  
Hospital Discharge ◽  
Severe Traumatic Brain Injury ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Clinical Practices

Abstract BackgroundPharmacological elevation of blood pressure is frequently incorporated in severe traumatic brain injury management algorithms. However, there is limited evidence on prevalent clinical practices regarding resuscitation for severe traumatic brain injury using vasopressors. We conducted a nationwide retrospective cohort study to determine the association between the use of vasopressors and mortality following hospital discharge in patients with severe traumatic brain injury, and to determine whether the use of vasopressors affects emergency department mortality or the occurrence of cognitive dysfunction.MethodsData were collected between January 2004 and December 2018 from the Japanese Trauma Data Bank, which includes data from 272 emergency hospitals in Japan. Adults aged ≥16 years with severe traumatic brain injury, without other major injuries, were examined. A severe traumatic brain injury was defined based on the Abbreviated Injury Scale code and a Glasgow Coma Scale score of 3–8 on admission. Multivariable analysis and propensity score matching were performed. Statistical significance was assessed using 95% confidence intervals (CIs).ResultsIn total, 10 284 patients were eligible for analysis, with 650 patients (6.32%) included in the vasopressor group and 9634 patients (93.68%) included in the non-vasopressor group. The proportion of deaths on hospital discharge was higher in the vasopressor group than in the non-vasopressor group (81.69% [531/650] vs. 40.21% [3,874/9,634]). This finding was confirmed by multivariable logistic regression analysis (adjusted odds ratio [OR], 5.71; 95% CI: 4.56–7.16). Regarding propensity score-matched patients, the proportion of deaths on hospital discharge remained higher in the vasopressor group than in the non-vasopressor group (81.66% [530/649] vs. 50.69% [329/649]) (OR, 4.33; 95% CI: 3.37–5.57). The vasopressor group had a higher emergency department mortality rate than the non-vasopressor group (8.01% [52/649] vs. 2.77% [18/649]) (OR, 3.05; 95% CI: 1.77–5.28). There was no reduction in complications of cognitive disorders in the vasopressor group (5.39% [35/649] vs. 5.55% [36/649]) (OR, 0.97; 95% CI: 0.60–1.57).ConclusionsIn this population, the use of vasopressors for severe traumatic brain injury was associated with higher mortality on hospital discharge. Our results suggest that vasopressors should be avoided in most cases of severe traumatic brain injury.

Blunt cerebrovascular injuries in severe traumatic brain injury: incidence, risk factors, and evolution

2017 ◽  
Vol 127 (1) ◽  
pp. 16-22 ◽  
Author(s):  
Pierre Esnault ◽  
Mickaël Cardinale ◽  
Henry Boret ◽  
Erwan D'Aranda ◽  
Ambroise Montcriol ◽  
...  
Keyword(s):  
Risk Factors ◽  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Anticoagulation Therapy ◽  
Spine Injury ◽  
Hemorrhagic Complication ◽  
Injury Incidence ◽  
Severe Tbi ◽  
Systemic Anticoagulation

OBJECTIVEBlunt cerebrovascular injuries (BCVIs) affect approximately 1% of patients with blunt trauma. An antithrombotic or anticoagulation therapy is recommended to prevent the occurrence or recurrence of neurovascular events. This treatment has to be carefully considered after severe traumatic brain injury (TBI), due to the risk of intracranial hemorrhage expansion. Thus, the physician in charge of the patient is confronted with a hemorrhagic and ischemic risk. The main objective of this study was to determine the incidence of BCVI after severe TBI.METHODSThe authors conducted a prospective, observational, single-center study including all patients with severe TBI admitted in the trauma center. Diagnosis of BCVI was performed using a 64-channel multidetector CT. Characteristics of the patients, CT scan results, and outcomes were collected. A multivariate logistic regression model was developed to determine the risk factors of BCVI. Patients in whom BCVI was diagnosed were treated with systemic anticoagulation.RESULTSIn total, 228 patients with severe TBI who were treated over a period of 7 years were included. The incidence of BCVI was 9.2%. The main risk factors were as follows: motorcycle crash (OR 8.2, 95% CI 1.9–34.8), fracture involving the carotid canal (OR 11.7, 95% CI 1.7–80.9), cervical spine injury (OR 13.5, 95% CI 3.1–59.4), thoracic trauma (OR 7.3, 95% CI 1.1–51.2), and hepatic lesion (OR 13.3, 95% CI 2.1–84.5). Among survivors, 82% of patients with BCVI received systemic anticoagulation therapy, beginning at a median of Day 1.5. The overall stroke rate was 19%. One patient had an intracranial hemorrhagic complication.CONCLUSIONSBlunt cerebrovascular injuries are frequent after severe TBI (incidence 9.2%). The main risk factors are high-velocity lesions and injuries near cervical arteries.

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