scholarly journals Characterising the dynamics of cerebral metabolic dysfunction following traumatic brain injury: A microdialysis study in 619 patients

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0260291
Author(s):  
Mathew R. Guilfoyle ◽  
Adel Helmy ◽  
Joseph Donnelly ◽  
Matthew G. Stovell ◽  
Ivan Timofeev ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Cerebral Perfusion ◽  
Cerebral Metabolism ◽  
Normal Brain ◽  
Intensive Care Treatment ◽  
Brain Tissue Oxygenation ◽  
Brain Physiology ◽  
Arterial Blood

Traumatic brain injury (TBI) is a major cause of death and disability, particularly amongst young people. Current intensive care management of TBI patients is targeted at maintaining normal brain physiology and preventing secondary injury. Microdialysis is an invasive monitor that permits real-time assessment of derangements in cerebral metabolism and responses to treatment. We examined the prognostic value of microdialysis parameters, and the inter-relationships with other neuromonitoring modalities to identify interventions that improve metabolism. This was an analysis of prospective data in 619 adult TBI patients requiring intensive care treatment and invasive neuromonitoring at a tertiary UK neurosciences unit. Patients had continuous measurement of intracranial pressure (ICP), arterial blood pressure (ABP), brain tissue oxygenation (PbtO2), and cerebral metabolism and were managed according to a standardized therapeutic protocol. Microdialysate was assayed hourly for metabolites including glucose, pyruvate, and lactate. Cerebral perfusion pressure (CPP) and cerebral autoregulation (PRx) were derived from the ICP and ABP. Outcome was assessed with the Glasgow Outcome Score (GOS) at 6 months. Relationships between monitoring variables was examined with generalized additive mixed models (GAMM). Lactate/Pyruvate Ratio (LPR) over the first 3 to 7 days following injury was elevated amongst patients with poor outcome and was an independent predictor of ordinal GOS (p<0.05). Significant non-linear associations were observed between LPR and cerebral glucose, CPP, and PRx (p<0.001 to p<0.05). GAMM models suggested improved cerebral metabolism (i.e. reduced LPR with CPP >70mmHg, PRx <0.1, PbtO2 >18mmHg, and brain glucose >1mM. Deranged cerebral metabolism is an important determinant of patient outcome following TBI. Variations in cerebral perfusion, oxygenation and glucose supply are associated with changes in cerebral LPR and suggest therapeutic interventions to improve cerebral metabolism. Future prospective studies are required to determine the efficacy of these strategies.

scholarly journals What is the optimal threshold for cerebral perfusion pressure following traumatic brain injury?

2003 ◽  
Vol 15 (6) ◽  
pp. 1-5 ◽  
Author(s):  
Paul Vespa
Keyword(s):  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Cerebral Perfusion Pressure ◽  
Cerebral Perfusion ◽  
Oxygen Supply ◽  
Perfusion Pressure ◽  
Cerebral Metabolism ◽  
Conflicting Evidence ◽  
Selection Of

Intensive care of the patient with traumatic brain injury centers on control of intracranial pressure and cerebral perfusion pressure (CPP). The optimal CPP by definition delivers an adequate supply of blood and oxygen to meet the metabolic demands of brain tissue. A great deal of controversy exists regarding the optimal CPP value, with disparate studies providing conflicting evidence for the use of supraphysiological CPP values. No study that accurately assesses the efficacy of normal CPP compared with elevated CPP has been performed, but several studies demonstrate that a CPP threshold exists on an individual basis for patients with TBI. The use of brain monitors of cerebral metabolism and oxygen supply may assist the clinician in the selection of the optimal CPP for an individual patient.

scholarly journals Differential influence of arterial blood glucose on cerebral metabolism following severe traumatic brain injury

Critical Care ◽  
2009 ◽  
Vol 13 (1) ◽  
pp. R13 ◽  
Author(s):  
Monika Holbein ◽  
Markus Béchir ◽  
Silke Ludwig ◽  
Jutta Sommerfeld ◽  
Silvia R Cottini ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Blood Glucose ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Cerebral Metabolism ◽  
Arterial Blood ◽  
Arterial Blood Glucose

scholarly journals Focally administered succinate improves cerebral metabolism in traumatic brain injury patients with mitochondrial dysfunction

2021 ◽  
pp. 0271678X2110421
Author(s):  
Abdelhakim Khellaf ◽  
Nuria Marco Garcia ◽  
Tamara Tajsic ◽  
Aftab Alam ◽  
Matthew G Stovell ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Energy Metabolism ◽  
Mitochondrial Dysfunction ◽  
Cerebral Metabolism ◽  
Tricarboxylic Acid Cycle ◽  
Resonance Spectroscopy ◽  
Brain Tissue Oxygenation ◽  
Clinical Algorithm ◽  
Management Protocol

Following traumatic brain injury (TBI), raised cerebral lactate/pyruvate ratio (LPR) reflects impaired energy metabolism. Raised LPR correlates with poor outcome and mortality following TBI. We prospectively recruited patients with TBI requiring neurocritical care and multimodal monitoring, and utilised a tiered management protocol targeting LPR. We identified patients with persistent raised LPR despite adequate cerebral glucose and oxygen provision, which we clinically classified as cerebral ‘mitochondrial dysfunction’ (MD). In patients with TBI and MD, we administered disodium 2,3-13C2 succinate (12 mmol/L) by retrodialysis into the monitored region of the brain. We recovered 13C-labelled metabolites by microdialysis and utilised nuclear magnetic resonance spectroscopy (NMR) for identification and quantification. Of 33 patients with complete monitoring, 73% had MD at some point during monitoring. In 5 patients with multimodality-defined MD, succinate administration resulted in reduced LPR(−12%) and raised brain glucose(+17%). NMR of microdialysates demonstrated that the exogenous 13C-labelled succinate was metabolised intracellularly via the tricarboxylic acid cycle. By targeting LPR using a tiered clinical algorithm incorporating intracranial pressure, brain tissue oxygenation and microdialysis parameters, we identified MD in TBI patients requiring neurointensive care. In these, focal succinate administration improved energy metabolism, evidenced by reduction in LPR. Succinate merits further investigation for TBI therapy.

scholarly journals Brain Temperature Influences Intracranial Pressure and Cerebral Perfusion Pressure After Traumatic Brain Injury: A CENTER TBI Study

2020 ◽  
Author(s):  
Tatiana Birg ◽  
Fabrizio Ortolano ◽  
Eveline J.A. Wiegers ◽  
Peter Smielewski ◽  
Yan Savchenko ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Cerebral Perfusion Pressure ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Brain Temperature ◽  
Mixed Effects ◽  
Wilcoxon Test ◽  
Brain Physiology

Abstract BackgroundAfter Traumatic Brain Injury (TBI) fever is frequent. Brain temperature, which is directly linked to body temperature, may influence brain physiology. Increased body and/or brain temperature may cause secondary brain damage, with deleterious effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and outcome. MethodsCENTER-TBI, a prospective, multicenter, longitudinal study on TBI in Europe and Israel, includes a high resolution (HR) cohort of patients with data sampled at high-frequency (from 100 Hz to 500 Hz). In this study, simultaneous BT, ICP and CPP recordings were investigated. A mixed effects linear model was used to examine the association between different BT levels and ICP. We additionally focused on changes of ICP and CPP during the episodes of BT changes (delta BT ≥0.5 °C, lasting from 15 minutes to 3 hours) up or down-wards. The significance of ICP and CPP variations was estimated with the paired samples Wilcoxon test. Results Twenty-one patients with 2435 hours of simultaneous BT and ICP monitoring were studied. All patients reached a BT of 38° and experienced at least one episode of ICP above 20 mmHg. The linear mixed effects model revealed an association between BT above 37.5°C and higher ICP levels that was not confirmed for lower BT. We identified 149 episodes of BT changes. During BT elevations (n=79) ICP increased while CPP was reduced; opposite ICP and CPP variations occurred during episodes of BT reduction (n=70). All these changes were of moderate clinical relevance, even if statistically significant (p<0.0001). It has to be noted, however, that a number of therapeutic interventions against intracranial hypertension was documented during those episodes.ConclusionPatients after TBI usually develop BT> 38° soon after the injury. Brain temperature may influence brain physiology, as reflected by ICP and CPP. An association between BT exceeding 37.5°C and a higher ICP was identified. The relationship between BT, ICP and CPP become clearer during rapid temperature changes.Trial registration: The core study was registered with ClinicalTrials.gov, number NCT02210221, registered on July 29, 2014

Judgments of Critical Care Nurses About Risk for Secondary Brain Injury

2010 ◽  
Vol 19 (3) ◽  
pp. 250-260 ◽  
Author(s):  
Molly McNett ◽  
Margaret Doheny ◽  
Carol A. Sedlak ◽  
Ruth Ludwick
Keyword(s):  
Intensive Care Unit ◽  
Traumatic Brain Injury ◽  
Intensive Care ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Oxygen Saturation ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Secondary Brain Injury ◽  
Intensive Care Unit Nurses

Background Interdisciplinary care for patients with traumatic brain injury focuses on treating the primary brain injury and limiting further brain damage from secondary injury. Intensive care unit nurses have an integral role in preventing secondary brain injury; however, little is known about factors that influence nurses’ judgments about risk for secondary brain injury. Objective To investigate which physiological and situational variables influence judgments of intensive care unit nurses about patients’ risk for secondary brain injury, management solely with nursing interventions, and management by consulting another member of the health care team. Methods A multiple segment factorial survey design was used. Vignettes reflecting the complexity of real-life scenarios were randomly generated by using different values of each independent variable. Surveys containing the vignettes were sent to nurses at 2 level I trauma centers. Multiple regression was used to determine which variables influenced judgments about secondary brain injury. Results Judgments about risk for secondary brain injury were influenced by a patient’s oxygen saturation, intracranial pressure, cerebral perfusion pressure, mechanism of injury, and primary diagnosis, as well as by nursing shift. Judgments about interventions were influenced by a patient’s oxygen saturation, intracranial pressure, and cerebral perfusion pressure and by nursing shift. The initial judgments made by nurses were the most significant variable predictive of follow-up judgments. Conclusions Nurses need standardized, evidence-based content for management of secondary brain injury in critically ill patients with traumatic brain injury.

scholarly journals Brain Temperature Influences Intracranial Pressure and Cerebral Perfusion Pressure After Traumatic Brain Injury: A CENTER-TBI Study

2021 ◽  
Author(s):  
Tatiana Birg ◽  
Fabrizio Ortolano ◽  
Eveline J. A. Wiegers ◽  
Peter Smielewski ◽  
Yan Savchenko ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Cerebral Perfusion Pressure ◽  
Cerebral Perfusion ◽  
Perfusion Pressure ◽  
Brain Temperature ◽  
Mixed Effects ◽  
Wilcoxon Test ◽  
Brain Physiology

Abstract Background After traumatic brain injury (TBI), fever is frequent. Brain temperature (BT), which is directly linked to body temperature, may influence brain physiology. Increased body and/or BT may cause secondary brain damage, with deleterious effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome. Methods Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI), a prospective multicenter longitudinal study on TBI in Europe and Israel, includes a high resolution cohort of patients with data sampled at a high frequency (from 100 to 500 Hz). In this study, simultaneous BT, ICP, and CPP recordings were investigated. A mixed-effects linear model was used to examine the association between different BT levels and ICP. We additionally focused on changes in ICP and CPP during the episodes of BT changes (Δ BT ≥ 0.5 °C lasting from 15 min to 3 h) up or downward. The significance of ICP and CPP variations was estimated with the paired samples Wilcoxon test (also known as Wilcoxon signed-rank test). Results Twenty-one patients with 2,435 h of simultaneous BT and ICP monitoring were studied. All patients reached a BT of 38 °C and experienced at least one episode of ICP above 20 mm Hg. The linear mixed-effects model revealed an association between BT above 37.5 °C and higher ICP levels that was not confirmed for lower BT. We identified 149 episodes of BT changes. During BT elevations (n = 79) ICP increased, whereas CPP was reduced; opposite ICP and CPP variations occurred during episodes of BT reduction (n = 70). All these changes were of moderate clinical relevance (increase of ICP of 4.5 and CPP decrease of 7.5 mm Hg for BT rise, and ICP reduction of 1.7 and CPP elevation of 3.7 mm Hg during BT defervescence), even if statistically significant (p < 0.0001). It has to be noted, however, that a number of therapeutic interventions against intracranial hypertension was documented during those episodes. Conclusions Patients after TBI usually develop BT > 38 °C soon after the injury. BT may influence brain physiology, as reflected by ICP and CPP. An association between BT exceeding 37.5 °C and a higher ICP was identified but not confirmed for lower BT ranges. The relationship between BT, ICP, and CPP become clearer during rapid temperature changes. During episodes of temperature elevation, BT seems to have a significant impact on ICP and CPP.

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