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Wang RH, Lu AL, Li HP, Ma ZH, Wu SB, Lu HJ, Wen WX, Huang Y, Wang LX, Yuan F. Prevalence, predictors, and outcomes of acute respiratory distress syndrome in severe stroke. Neurol Sci 2024; 45:2719-2728. [PMID: 38150131 DOI: 10.1007/s10072-023-07269-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/14/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES Patients with severe stroke are at high risk of developing acute respiratory distress syndrome (ARDS), but this severe complication was often under-diagnosed and rarely explored in stroke patients. We aimed to investigate the prevalence, early predictors, and outcomes of ARDS in severe stroke. METHODS This prospective study included consecutive patients admitted to neurological intensive care unit (neuro-ICU) with severe stroke, including acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The incidence of ARDS was examined, and baseline characteristics and severity scores on admission were investigated as potential early predictors for ARDS. The in-hospital mortality, length of neuro-ICU stay, the total cost in neuro-ICU, and neurological functions at 90 days were explored. RESULTS Of 140 patients included, 35 (25.0%) developed ARDS. Over 90% of ARDS cases occurred within 1 week of admission. Procalcitonin (OR 1.310 95% CI 1.005-1.707, P = 0.046) and PaO2/FiO2 on admission (OR 0.986, 95% CI 0.979-0.993, P < 0.001) were independently associated with ARDS, and high brain natriuretic peptide (OR 0.994, 95% CI 0.989-0.998, P = 0.003) was a red flag biomarker warning that the respiratory symptoms may be caused by cardiac failure rather than ARDS. ARDS patients had longer stays and higher expenses in neuro-ICU. Among patients with ARDS, 25 (62.5%) were moderate or severe ARDS. All the patients with moderate to severe ARDS had an unfavorable outcome at 90 days. CONCLUSIONS ARDS is common in patients with severe stroke, with most cases occurring in the first week of admission. Procalcitonin and PaO2/FiO2 on admission are early predictors of ARDS. ARDS worsens both short-term and long-term outcomes. The conflict in respiratory support strategies between ARDS and severe stroke needs to be further studied.
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Affiliation(s)
- Rui-Hong Wang
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
| | - Ai-Li Lu
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hui-Ping Li
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhao-Hui Ma
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shi-Biao Wu
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hong-Ji Lu
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wan-Xin Wen
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan Huang
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Research On Emergency in TCM, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Li-Xin Wang
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China.
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Research On Emergency in TCM, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Guangzhou, Guangdong, China.
| | - Fang Yuan
- The Second Clinical College of Guangzhou, University of Chinese Medicine, Guangzhou, China.
- Department of Neurocritical Care, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- State Key Laboratory of Traditional Chinese Medicine Syndrome, Guangzhou, Guangdong, China.
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2
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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3
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Taran S, Stevens RD, Perrot B, McCredie VA, Cinotti R, Asehnoune K, Pelosi P, Robba C. Incidence and Outcomes of Acute Respiratory Distress Syndrome in Brain-Injured Patients Receiving Invasive Ventilation: A Secondary Analysis of the ENIO Study. J Intensive Care Med 2024; 39:136-145. [PMID: 37563968 PMCID: PMC10771027 DOI: 10.1177/08850666231194532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Background: Acute respiratory distress syndrome (ARDS) is an important pulmonary complication in brain-injured patients receiving invasive mechanical ventilation (IMV). We aimed to evaluate the incidence and association between ARDS and clinical outcomes in patients with different forms of acute brain injury requiring IMV in the intensive care unit (ICU). Methods: This was a preplanned secondary analysis of a prospective, multicenter, international cohort study (NCT03400904). We included brain-injured patients receiving IMV for ≥ 24 h. ARDS was the main exposure of interest and was identified during index ICU admission using the Berlin definition. We examined the incidence and adjusted association of ARDS with ICU mortality, ICU length of stay, duration of IMV, and extubation failure. Outcomes were evaluated using mixed-effect logistic regression and cause-specific Cox proportional hazards models. Results: 1492 patients from 67 hospitals and 16 countries were included in the analysis, of whom 137 individuals developed ARDS (9.2% of overall cohort). Across countries, the median ARDS incidence was 5.1% (interquartile range [IQR] 0-10; range 0-27.3). ARDS was associated with increased ICU mortality (adjusted odds ratio (OR) 2.66; 95% confidence interval [CI], 1.29-5.48), longer ICU length of stay (adjusted hazard ratio [HR] 0.59; 95% CI, 0.48-0.73), and longer duration of IMV (adjusted HR 0.54; 95% CI, 0.44-0.67). The association between ARDS and extubation failure approached statistical significance (adjusted HR 1.48; 95% CI 0.99-2.21). Higher ARDS severity was associated with incrementally longer ICU length of stay and longer cumulative duration of IMV. Findings remained robust in a sensitivity analysis evaluating the magnitude of unmeasured confounding. Conclusions: In this cohort of acutely brain-injured patients, the incidence of ARDS was similar to that reported in other mixed cohorts of critically ill patients. Development of ARDS was associated with worse outcomes.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert D. Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Bastien Perrot
- UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes Université, Tours Université, Nantes, France
| | - Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Raphael Cinotti
- UMR 1246 MethodS in Patient-centered outcomes and HEalth REsearch, SPHERE, Nantes Université, Tours Université, Nantes, France
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel-Dieu, Nantes, France
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel-Dieu, Nantes, France
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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4
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Austin SE, Galvagno SM, Podell JE, Teeter WA, Kundi R, Haase DJ, Taylor BS, Betzold R, Stein DM, Scalea TM, Powell EK. Venovenous extracorporeal membrane oxygenation in patients with traumatic brain injuries and severe respiratory failure: A single-center retrospective analysis. J Trauma Acute Care Surg 2024; 96:332-339. [PMID: 37828680 DOI: 10.1097/ta.0000000000004159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Venovenous extracorporeal membrane oxygenation (VV ECMO) can support trauma patients with severe respiratory failure. Use in traumatic brain injury (TBI) may raise concerns of worsening complications from intracranial bleeding. However, VV ECMO can rapidly correct hypoxemia and hypercarbia, possibly preventing secondary brain injury. We hypothesize that adult trauma patients with TBI on VV ECMO have comparable survival with trauma patients without TBI. METHODS A single-center, retrospective cohort study involving review of electronic medical records of trauma admissions between July 1, 2014, and August 30, 2022, with discharge diagnosis of TBI who were placed on VV ECMO during their hospital course was performed. RESULTS Seventy-five trauma patients were treated with VV ECMO; 36 (48%) had TBI. Of those with TBI, 19 (53%) had a hemorrhagic component. Survival was similar between patients with and without a TBI (72% vs. 64%, p = 0.45). Traumatic brain injury survivors had a higher admission Glasgow Coma Scale (7 vs. 3, p < 0.001) than nonsurvivors. Evaluation of prognostic scoring systems on initial head computed tomography demonstrated that TBI VV ECMO survivors were more likely to have a Rotterdam score of 2 (62% vs. 20%, p = 0.03) and no survivors had a Marshall score of ≥4. Twenty-nine patients (81%) had a repeat head computed tomography on VV ECMO with one incidence of expanding hematoma and one new focus of bleeding. Neither patient with a new/worsening bleed received anticoagulation. Survivors demonstrated favorable neurologic outcomes at discharge and outpatient follow-up, based on their mean Rancho Los Amigos Scale (6.5; SD, 1.2), median Cerebral Performance Category (2; interquartile range, 1-2), and median Glasgow Outcome Scale-Extended (7.5; interquartile range, 7-8). CONCLUSION In this series, the majority of TBI patients survived and had good neurologic outcomes despite a low admission Glasgow Coma Scale. Venovenous extracorporeal membrane oxygenation may minimize secondary brain injury and may be considered in select patients with TBI. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Samuel E Austin
- From the Program in Trauma (S.E.A., W.A.T., R.K., D.J.H., D.M.S., T.M.S., E.K.P.), R Adams Cowley Shock Trauma Center, Department of Surgery (S.E.A., R.K., D.J.H., D.M.S., T.M.S.), Department of Anesthesiology (S.M.G.), Neurocritical Care (J.E.P.), Program in Trauma, Department of Neurology, Department of Emergency Medicine (W.A.T., D.J.H., E.K.P.), and Department of Surgery (B.S.T.), Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and Department of Trauma and Acute Care Surgery (R.B.), University of Alabama at Birmingham, Birmingham, Alabama
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5
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Cralley AL, Erickson C, Schaid TR, Hallas W, Thielen O, Mitra S, Stafford P, Hom P, Silliman C, Cohen MJ, Moore EE, D'Alessandro A, Hansen KC. The proteomic and metabolomic signatures of isolated and polytrauma traumatic brain injury. Am J Surg 2023; 226:790-797. [PMID: 37541795 DOI: 10.1016/j.amjsurg.2023.07.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/02/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND The interactions of polytrauma, shock, and traumatic brain injury (TBI) on thromboinflammatory responses remain unclear and warrant investigation as we strive towards personalized medicine in trauma. We hypothesized that comprehensive omics characterization of plasma would identify unique metabolic and thromboinflammatory pathways following TBI. METHODS Patients were categorized as TBI vs Non-TBI, and stratified into Polytrauma or minimally injured. Discovery 'omics was employed to quantify the top differently expressed proteins and metabolites of TBI and Non-TBI patient groups. RESULTS TBI compared to Non-TBI showed gene enrichment in coagulation/complement cascades and neuronal markers. TBI was associated with elevation in glycolytic metabolites and conjugated bile acids. Division into isolated TBI vs polytrauma showed further distinction of proteomic and metabolomic signatures. CONCLUSION Identified mediators involving in neural inflammation, blood brain barrier disruption, and bile acid building leading to TBI associated coagulopathy offer suggestions for follow up mechanistic studies to target personalized interventions.
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Affiliation(s)
| | - Chris Erickson
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO, USA
| | - Terry R Schaid
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - William Hallas
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Otto Thielen
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | | | - Patrick Hom
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Christopher Silliman
- Vitalant Research Institute, Denver, CO, USA; Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO, USA; Ernest E. Moore Shock Trauma Center at Denver Health Medical Center Surgery, Aurora, CO, USA
| | - Angelo D'Alessandro
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO, USA
| | - Kirk C Hansen
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO, USA
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6
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Lokhande UR, Thakre VM, Sharath HV. Effect of Chest Physiotherapy Technique on Bilateral Bronchial Pneumonia Secondary to Acute Respiratory Distress Syndrome: A Case Report. Cureus 2023; 15:e50437. [PMID: 38222163 PMCID: PMC10784773 DOI: 10.7759/cureus.50437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/13/2023] [Indexed: 01/16/2024] Open
Abstract
This case report investigates the impact of a specific chest physiotherapy technique on a patient with bilateral bronchial pneumonia secondary to acute respiratory distress syndrome (ARDS). ARDS is a life-threatening condition characterized by severe respiratory failure, and bronchial pneumonia can further complicate the clinical course. The chosen chest physiotherapy technique aims to improve respiratory function and alleviate symptoms in the context of this challenging scenario. ARDS can develop in individuals who are seriously injured or have other severe conditions. ARDS is characterized by insensitive cyanosis, declining lung compliance, and high morbidity in intensive care units. It is a complicated and accumulating condition that develops from acute damage to the lungs. The case involves a detailed examination of a patient diagnosed with bilateral bronchial pneumonia as a complication of ARDS. The application of a targeted chest physiotherapy technique is described, emphasizing its methodology and the rationale behind its selection. Through this case report, we aim to contribute valuable insights into the potential efficacy of the specific chest physiotherapy technique for managing respiratory complications associated with ARDS-induced bilateral bronchial pneumonia. The findings may have implications for clinical practice, guiding healthcare professionals in tailoring interventions for similar cases and optimizing patient care in critical respiratory conditions. Additionally, the report underscores the importance of individualized approaches in the management of complex respiratory disorders, highlighting the need for further research to validate and refine such therapeutic strategies. The report delves into the patient's response to the intervention, documenting any observable improvements in respiratory parameters, lung function, and overall clinical outcomes. There were numerous etiologists, and it frequently ended in intense respiratory failure; after that death, the majority of care is supportive and concentrates on treating the underlying cause as well as providing ventilation. Physical therapy should begin as soon as the ARDS is treated. In this case, we discuss and conclude the various aspects of physiotherapy interventions for bilateral bronchial pneumonia secondary to ARDS. Chest physiotherapy plays an important role in respiratory conditions for breathing effectiveness and to reduce airway resistance.
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Affiliation(s)
- Urvini R Lokhande
- Department of Paediatric Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vaishnavi M Thakre
- Department of Paediatric Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - H V Sharath
- Department of Paediatric Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hung T, Lam N. Risk Factors for Death of Burn Patients With Acute Respiratory Distress Syndrome. ANNALS OF BURNS AND FIRE DISASTERS 2023; 36:271-275. [PMID: 38680242 PMCID: PMC11041865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/02/2022] [Indexed: 05/01/2024]
Abstract
The aim of this study was to investigate factors independently affecting outcomes of post-burn ARDS patients at the time of ARDS onset. A prospective study was conducted on 66 patients with ARDS, treated in the ICU at the Le Huu Trac National Burns Hospital in Hanoi, Viet Nam, from 2014 to 2017. Patients were divided into a survivor and non-survivor group. Demographic criteria, burn severity, inhalation injury, clinical and subclinical features at ARDS onset were compared between the two groups. The results showed that overall mortality of ARDS patients was 62.12%. Logistic regression analysis indicated that at the time of ARDS onset, serum lactate level (OR=6.71), blood platelet count (OR=.99), static lung compliance (OR=.73) and driving pressure (OR=1.69) were independent risk factors for death, while patients' demographics, burn severity and ARDS severity did not significantly affect the mortality rate.
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Affiliation(s)
| | - N.N. Lam
- Le Huu Trac National Burn Hospital & Viet Nam Medical Military University, Hanoi, Viet Nam
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8
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Frisvold S, Coppola S, Ehrmann S, Chiumello D, Guérin C. Respiratory challenges and ventilatory management in different types of acute brain-injured patients. Crit Care 2023; 27:247. [PMID: 37353832 PMCID: PMC10290317 DOI: 10.1186/s13054-023-04532-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/15/2023] [Indexed: 06/25/2023] Open
Abstract
Acute brain injury (ABI) covers various clinical entities that may require invasive mechanical ventilation (MV) in the intensive care unit (ICU). The goal of MV, which is to protect the lung and the brain from further injury, may be difficult to achieve in the most severe forms of lung or brain injury. This narrative review aims to address the respiratory issues and ventilator management, specific to ABI patients in the ICU.
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Affiliation(s)
- S Frisvold
- Department of Anesthesia and Intensive Care, University Hospital of North Norway, Tromso, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromso, Norway
| | - S Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - S Ehrmann
- CHRU Tours, Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep F-CRIN Research Network, Tours, France
- INSERM, Centre d'étude Des Pathologies Respiratoires, U1100, Université de Tours, Tours, France
| | - D Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center On Respiratory Failure, University of Milan, Milan, Italy
| | - Claude Guérin
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France.
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Taran S, Hamad DM, von Düring S, Malhotra AK, Veroniki AA, McCredie VA, Singh JM, Hansen B, Englesakis M, Adhikari NKJ. Factors associated with acute respiratory distress syndrome in brain-injured patients: A systematic review and meta-analysis. J Crit Care 2023; 77:154341. [PMID: 37235919 DOI: 10.1016/j.jcrc.2023.154341] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 05/28/2023]
Abstract
PURPOSE Acute respiratory distress syndrome (ARDS) is common in patients with acute brain injury admitted to the ICU. We aimed to identify factors associated with ARDS in this population. METHODS We searched MEDLINE, Embase, Cochrane Central, Scopus, and Web of Science from inception to January 14, 2022. Three reviewers independently screened articles and selected English-language studies reporting risk factors for ARDS in brain-injured adult patients. Data were extracted on ARDS incidence, adjusted and unadjusted risk factors, and clinical outcomes. Risk of bias was reported using the Quality in Prognostic Studies tool. Certainty of evidence was assessed using GRADE. RESULTS We selected 23 studies involving 6,961,284 patients with acute brain injury. The pooled cumulative incidence of ARDS after brain injury was 17.0% (95%CI 10.7-25.8). In adjusted analysis, factors associated with ARDS included sepsis (odds ratio (OR) 4.38, 95%CI 2.37-8.10; high certainty), history of hypertension (OR 3.11, 95%CI 2.31-4.19; high certainty), pneumonia (OR 2.69, 95%CI 2.35-3.10; high certainty), acute kidney injury (OR 1.44, 95%CI 1.30-1.59; moderate certainty), admission hypoxemia (OR 1.67, 95%CI 1.29-2.17; moderate certainty), male sex (OR 1.30, 95%CI 1.06-1.58; moderate certainty), and chronic obstructive pulmonary disease (OR 1.27, 95%CI 1.13-1.44; moderate certainty). Development of ARDS was independently associated with increased odds of in-hospital mortality (OR 3.12, 95% CI 1.39-7.00). CONCLUSIONS Multiple risk factors are associated with ARDS in brain-injured patients. These findings could be used to develop prognostic models for ARDS or as prognostic enrichment strategies for patient enrolment in future clinical trials.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Neurology, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
| | - Doulia M Hamad
- Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Stephan von Düring
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Intensive Care Division, Geneva University Hospitals (HUG) and Faculty of Medicine, University of Geneva, Switzerland
| | - Armaan K Malhotra
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Areti Angeliki Veroniki
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bettina Hansen
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Marina Englesakis
- Library and Health Information Services, University Health Network, Toronto, ON, Canada
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Dias C, de Castro A, Gaio R, Silva R, Pereira E, Monteiro E. Lung Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy. J Crit Care Med (Targu Mures) 2023; 9:97-105. [PMID: 37593249 PMCID: PMC10429626 DOI: 10.2478/jccm-2023-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/31/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications. Aim of the study We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome. Methods and results Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO2/FiO2) was 305±88 and driving pressure 15.9±3.5cmH2O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found. Conclusion Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.
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Affiliation(s)
- Celeste Dias
- Faculty of Medicine, University of Porto, Porto, Portugal
- University Hospital Centre São João, PortoPortugal
| | | | - Rita Gaio
- Faculty of Mathematics, University of Porto, Porto, Portugal
- Centre of Mathematics of the University of Porto, Porto, Portugal
| | - Ricardo Silva
- Faculty of Mathematics, University of Porto, Porto, Portugal
| | | | - Elisabete Monteiro
- Faculty of Medicine, University of Porto, Porto, Portugal
- University Hospital Centre São João, PortoPortugal
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Prediction of Acute Respiratory Distress Syndrome in Traumatic Brain Injury Patients Based on Machine Learning Algorithms. Medicina (B Aires) 2023; 59:medicina59010171. [PMID: 36676795 PMCID: PMC9864532 DOI: 10.3390/medicina59010171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/07/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Background: Acute respiratory distress syndrome (ARDS) commonly develops in traumatic brain injury (TBI) patients and is a risk factor for poor prognosis. We designed this study to evaluate the performance of several machine learning algorithms for predicting ARDS in TBI patients. Methods: TBI patients from the Medical Information Mart for Intensive Care-III (MIMIC-III) database were eligible for this study. ARDS was identified according to the Berlin definition. Included TBI patients were divided into the training cohort and the validation cohort with a ratio of 7:3. Several machine learning algorithms were utilized to develop predictive models with five-fold cross validation for ARDS including extreme gradient boosting, light gradient boosting machine, Random Forest, adaptive boosting, complement naïve Bayes, and support vector machine. The performance of machine learning algorithms were evaluated by the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, accuracy and F score. Results: 649 TBI patients from the MIMIC-III database were included with an ARDS incidence of 49.5%. The random forest performed the best in predicting ARDS in the training cohort with an AUC of 1.000. The XGBoost and AdaBoost ranked the second and the third with an AUC of 0.989 and 0.815 in the training cohort. The random forest still performed the best in predicting ARDS in the validation cohort with an AUC of 0.652. AdaBoost and XGBoost ranked the second and the third with an AUC of 0.631 and 0.620 in the validation cohort. Several mutual top features in the random forest and AdaBoost were discovered including age, initial systolic blood pressure and heart rate, Abbreviated Injury Score chest, white blood cells, platelets, and international normalized ratio. Conclusions: The random forest and AdaBoost based models have stable and good performance for predicting ARDS in TBI patients. These models could help clinicians to evaluate the risk of ARDS in early stages after TBI and consequently adjust treatment decisions.
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12
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The Risk Factors for Mortality among Septic Trauma Patients: A Retrospective Cohort Study Using the National Trauma Data Bank. Emerg Med Int 2022; 2022:6386078. [PMID: 36619805 PMCID: PMC9822740 DOI: 10.1155/2022/6386078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/12/2022] [Accepted: 12/09/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction In trauma patients, the development of sepsis as a hospital complication is significantly associated with morbidity and mortality. We aimed to assess the risk factors associated with in-hospital mortality among trauma patients who developed sepsis during their hospital stay. Material and methods. Using the 2017 National Trauma Data Bank, a retrospective cohort study was conducted to identify adult trauma patients who developed sepsis during their hospital stay. The primary outcome of interest was in-hospital mortality. Multivariate analysis was used to determine the risk factors associated with in-hospital mortality. Results 1782 trauma patients developed sepsis. 567 patients (31.8%) died during their hospital stay. The following patient factors were associated with higher odds of in-hospital mortality: age (OR = 1.045 95% CI = 1.036-1.054), chronic renal failure (OR = 2.564 95% CI = 1.528-4.301), and liver cirrhosis (OR = 3.699 95% CI = 2.267-6.033). Patients who developed cardiac arrest (OR = 4.994 95% CI = 3.381-7.378), acute kidney injury (OR = 3.808 95% CI = 2.837-5.110), acute respiratory distress syndrome (OR = 1.688 95% CI = 1.197-2.379), and stroke (OR = 1.998 95% CI = 1.075-3.714) during their hospital stay had higher odds of mortality. Higher Glasgow Coma Scale (13-15) at presentation was associated with lower odds of mortality (OR = 0.467 95% CI = 0.328-0.667). Conclusion Among trauma patients who developed sepsis, age, chronic renal failure, cirrhosis, the development of cardiac arrest, acute kidney injury, acute respiratory distress syndrome, and stroke in the hospital were associated with in-hospital mortality. These factors can be used to identify patients who are at higher risk of adverse outcomes and implement standardized or protocol-driven methods to improve patient care.
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13
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Toro C, Hatfield J, Temkin N, Barber J, Manley G, Ohnuma T, Komisarow J, Foreman B, Korley FK, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Raghunathan K, Goldstein BA, Markowitz AJ, Krishnamoorthy V. Risk Factors and Neurological Outcomes Associated With Circulatory Shock After Moderate-Severe Traumatic Brain Injury: A TRACK-TBI Study. Neurosurgery 2022; 91:427-436. [PMID: 35593705 PMCID: PMC10553078 DOI: 10.1227/neu.0000000000002042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/03/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Extracranial multisystem organ failure is a common sequela of severe traumatic brain injury (TBI). Risk factors for developing circulatory shock and long-term functional outcomes of this patient subset are poorly understood. OBJECTIVE To identify emergency department predictors of circulatory shock after moderate-severe TBI and examine long-term functional outcomes in patients with moderate-severe TBI who developed circulatory shock. METHODS We conducted a retrospective cohort study using the Transforming Clinical Research and Knowledge in TBI database for adult patients with moderate-severe TBI, defined as a Glasgow Coma Scale (GCS) score of <13 and stratified by the development of circulatory shock within 72 hours of hospital admission (Sequential Organ Failure Assessment score ≥2). Demographic and clinical data were assessed with descriptive statistics. A forward selection regression model examined risk factors for the development of circulatory shock. Functional outcomes were examined using multivariable regression models. RESULTS Of our moderate-severe TBI population (n = 407), 168 (41.2%) developed circulatory shock. Our predictive model suggested that race, computed tomography Rotterdam scores <3, GCS in the emergency department, and development of hypotension in the emergency department were associated with developing circulatory shock. Those who developed shock had less favorable 6-month functional outcomes measured by the 6-month GCS-Extended (odds ratio 0.36, P = .002) and 6-month Disability Rating Scale score (Diff. in means 3.86, P = .002) and a longer length of hospital stay (Diff. in means 11.0 days, P < .001). CONCLUSION We report potential risk factors for circulatory shock after moderate-severe TBI. Our study suggests that developing circulatory shock after moderate-severe TBI is associated with poor long-term functional outcomes.
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Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Jordan Hatfield
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Nancy Temkin
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Jordan Komisarow
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Frederick K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Joseph P. Mathew
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Adrian Hernandez
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - John Sampson
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Michael L. James
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Benjamin A. Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, California, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
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14
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Matin N, Sarhadi K, Crooks CP, Lele AV, Srinivasan V, Johnson NJ, Robba C, Town JA, Wahlster S. Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80-120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Affiliation(s)
- Nassim Matin
- Department of Neurology, University of Washington, Seattle, WA USA
| | - Kasra Sarhadi
- Department of Neurology, University of Washington, Seattle, WA USA
| | | | - Abhijit V. Lele
- Department of Anesthesiology, University of Washington, Seattle, WA USA
- Department of Neurological Surgery, University of Washington, Seattle, WA USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, WA USA
| | - Nicholas J. Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA
| | - Chiara Robba
- Departments of Anesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), Genoa, Italy
| | - James A. Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, WA USA
- Department of Anesthesiology, University of Washington, Seattle, WA USA
- Department of Neurological Surgery, University of Washington, Seattle, WA USA
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15
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Ke Y, Proctor JL, Zhang C, Medina J, Miller CHT, Kim J, Grissom TE, Birukova AA, Fiskum GM, Birukov KG. Induction of endothelial barrier dysfunction by serum factors in rats subjected to traumatic brain injury and hemorrhagic shock. Physiol Rep 2022; 10:e15350. [PMID: 35785527 PMCID: PMC9251847 DOI: 10.14814/phy2.15350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/18/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023] Open
Abstract
Traumatic brain injury (TBI) has been associated with the development of indirect acute respiratory distress syndrome (ARDS). However, the causative relationship between TBI and lung injury remains unclear. To explore potential mechanisms linking TBI with the development of ARDS, we characterized the effects of serum factors released following TBI and hemorrhagic shock (HS) in a rat model on the pulmonary endothelial cell (EC) barrier dysfunction, a key feature of ARDS. We found that serum samples from animals exposed to both controlled cortical impact (CCI) and HS, but not from sham-operated rats induced significant barrier dysfunction in human pulmonary artery EC monolayers at 2 days post injury. Thrombin inhibitor and thrombin receptor antagonist attenuated the acute phase of the serum-induced trans-endothelial resistance (TER) decline caused by CCI-HS serum, but not in later time points. However, both the early and late phases of CCI-HS-induced EC permeability were inhibited by heparin. The barrier disruptive effects of CCI-HS serum were also prevented by serum preincubation with heparin-sepharose. Pulmonary EC treated for 3 h with serum from CCI-HS rats demonstrated a significant decline in expression of EC junctional protein, VE-Cadherin, and disassembly of peripheral EC adherens junction complexes monitored by immunostaining with VE-cadherin antibody. These results suggest that exposure to CCI-HS causes early and late-phase barrier disruptive effects in vascular endothelium. While thrombin-PAR1 signaling has been identified as a mechanism of acute EC permeability increase by CCI-HS serum, the factor(s) defining long-term EC barrier disruption in CCI-HS model remains to be determined.
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Affiliation(s)
- Yunbo Ke
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Julie L. Proctor
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Chenou Zhang
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Juliana Medina
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Catriona H. T. Miller
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Junghyun Kim
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Thomas E. Grissom
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Anna A. Birukova
- Division of Pulmonary and Critical Care MedicineDepartment of MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Gary M. Fiskum
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Konstantin G. Birukov
- Department of AnesthesiologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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16
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Predictors of mortality in trauma patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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Movahedpour A, Vakili O, Khalifeh M, Mousavi P, Mahmoodzadeh A, Taheri-Anganeh M, Razmeh S, Shabaninejad Z, Yousefi F, Behrouj H, Ghasemi H, Khatami SH. Mammalian target of rapamycin (mTOR) signaling pathway and traumatic brain injury: A novel insight into targeted therapy. Cell Biochem Funct 2022; 40:232-247. [PMID: 35258097 DOI: 10.1002/cbf.3692] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
Abstract
Traumatic brain injury (TBI) is one of the most concerning health issues in which the normal brain function may be disrupted as a result of a blow, bump, or jolt to the head. Loss of consciousness, amnesia, focal neurological defects, alteration in mental state, and destructive diseases of the nervous system such as cognitive impairment, Parkinson's, and Alzheimer's disease. Parkinson's disease is a chronic progressive neurodegenerative disorder, characterized by the early loss of striatal dopaminergic neurons. TBI is a major risk factor for Parkinson's disease. Existing therapeutic approaches have not been often effective, indicating the necessity of discovering more efficient therapeutic targets. The mammalian target of rapamycin (mTOR) signaling pathway responds to different environmental cues to modulate a large number of cellular processes such as cell proliferation, survival, protein synthesis, autophagy, and cell metabolism. Moreover, mTOR has been reported to affect the regeneration of the injured nerves throughout the central nervous system (CNS). In this context, recent evaluations have revealed that mTOR inhibitors could be potential targets to defeat a group of neurological disorders, and thus, a number of clinical trials are investigating their efficacy in treating dementia, autism, epilepsy, stroke, and brain injury, as irritating neurological defects. The current review describes the interplay between mTOR signaling and major CNS-related disorders (esp. neurodegenerative diseases), as well as the mTOR signaling-TBI relationship. It also aims to discuss the promising therapeutic capacities of mTOR inhibitors during the TBI.
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Affiliation(s)
| | - Omid Vakili
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoomeh Khalifeh
- Department of Medical Biotechnology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pegah Mousavi
- Department of Medical Genetics, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Amir Mahmoodzadeh
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mortaza Taheri-Anganeh
- Cellular and Molecular Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran
| | - Saeed Razmeh
- Department of Internal Medicine, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Zahra Shabaninejad
- Department of Nanobiotechnology, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Fatemeh Yousefi
- Department of Genetics, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran
| | - Hamid Behrouj
- Behbahan Faculty of Medical Sciences, Behbahan, Iran
| | | | - Seyyed Hossein Khatami
- Department of Clinical Biochemistry, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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18
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Taran S, McCredie VA, Goligher EC. Noninvasive and invasive mechanical ventilation for neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:361-386. [PMID: 36031314 DOI: 10.1016/b978-0-323-91532-8.00015-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada.
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19
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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20
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Tran A, Fernando SM, Brochard LJ, Fan E, Inaba K, Ferguson ND, Calfee CS, Burns KEA, Brodie D, McCredie VA, Kim DY, Kyeremanteng K, Lampron J, Slutsky AS, Combes A, Rochwerg B. Prognostic factors for development of acute respiratory distress syndrome following traumatic injury - a systematic review and meta-analysis. Eur Respir J 2021; 59:13993003.00857-2021. [PMID: 34625477 DOI: 10.1183/13993003.00857-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/17/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE To summarise the prognostic associations between various clinical risk factors and the development of the acute respiratory distress syndrome (ARDS) following traumatic injury. METHODS We conducted this review in accordance with the PRISMA and CHARMS guidelines. We searched six databases from inception through December 2020. We included English language studies describing the clinical risk factors associated with the development of post-traumatic ARDS, as defined by either the American-European Consensus Conference or the Berlin definition. We pooled adjusted odds ratios for prognostic factors using the random effects method. We assessed risk of bias using the QUIPS tool and certainty of findings using GRADE methodology. RESULTS We included 39 studies involving 5 350 927 patients. We identified the amount of crystalloid resuscitation as a potentially modifiable prognostic factor associated with the development of post-traumatic ARDS (adjusted odds ratio [aOR] 1.19 for each additional liter of crystalloid administered within first 6 h after injury, 95% CI 1.15 to 1.24, high certainty). Non-modifiable prognostic factors with a moderate or high certainty of association with post-traumatic ARDS included increasing age, non-Hispanic white race, blunt mechanism of injury, presence of head injury, pulmonary contusion, or rib fracture; and increasing chest injury severity. CONCLUSION We identified one important modifiable factor, the amount of crystalloid resuscitation within the first 24 h of injury, and several non-modifiable factors associated with development of post-traumatic ARDS. This information should support the judicious use of crystalloid resuscitation in trauma patients and may inform the development of a risk-stratification tools.
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Affiliation(s)
- Alexandre Tran
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Dennis Y Kim
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM Unite Mixte de Recherche (UMRS) 1166, Paris, France.,Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Pitié-Salpêtrière, Paris, France
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
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21
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Krishnamoorthy V, Temkin N, Barber J, Foreman B, Komisarow J, Korley FK, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Bartz R, Raghunathan K, Goldstein BA, Markowitz AJ, Vavilala MS. Association of Early Multiple Organ Dysfunction With Clinical and Functional Outcomes Over the Year Following Traumatic Brain Injury: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study. Crit Care Med 2021; 49:1769-1778. [PMID: 33935162 PMCID: PMC8448900 DOI: 10.1097/ccm.0000000000005055] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Traumatic brain injury is a leading cause of death and disability in the United States. While the impact of early multiple organ dysfunction syndrome has been studied in many critical care paradigms, the clinical impact of early multiple organ dysfunction syndrome in traumatic brain injury is poorly understood. We examined the incidence and impact of early multiple organ dysfunction syndrome on clinical, functional, and disability outcomes over the year following traumatic brain injury. DESIGN Retrospective cohort study. SETTING Patients enrolled in the Transforming Clinical Research and Knowledge in Traumatic Brain Injury study, an 18-center prospective cohort study of traumatic brain injury patients evaluated in participating level 1 trauma centers. SUBJECTS Adult (age > 17 yr) patients with moderate-severe traumatic brain injury (Glasgow Coma Scale < 13). We excluded patients with major extracranial injury (Abbreviated Injury Scale score ≥ 3). INTERVENTIONS Development of early multiple organ dysfunction syndrome, defined as a maximum modified Sequential Organ Failure Assessment score greater than 7 during the initial 72 hours following admission. MEASUREMENTS AND MAIN RESULTS The main outcomes were: hospital mortality, length of stay, 6-month functional and disability domains (Glasgow Outcome Scale-Extended and Disability Rating Scale), and 1-year mortality. Secondary outcomes included: ICU length of stay, 3-month Glasgow Outcome Scale-Extended, 3-month Disability Rating Scale, 1-year Glasgow Outcome Scale-Extended, and 1-year Disability Rating Scale. We examined 373 subjects with moderate-severe traumatic brain injury. The mean (sd) Glasgow Coma Scale in the emergency department was 5.8 (3.2), with 280 subjects (75%) classified as severe traumatic brain injury (Glasgow Coma Scale 3-8). Among subjects with moderate-severe traumatic brain injury, 252 (68%) developed early multiple organ dysfunction syndrome. Subjects that developed early multiple organ dysfunction syndrome had a 75% decreased odds of a favorable outcome (Glasgow Outcome Scale-Extended 5-8) at 6 months (adjusted odds ratio, 0.25; 95% CI, 0.12-0.51) and increased disability (higher Disability Rating Scale score) at 6 months (adjusted mean difference, 2.04; 95% CI, 0.92-3.17). Subjects that developed early multiple organ dysfunction syndrome experienced an increased hospital length of stay (adjusted mean difference, 11.4 d; 95% CI, 7.1-15.8), with a nonsignificantly decreased survival to hospital discharge (odds ratio, 0.47; 95% CI, 0.18-1.2). CONCLUSIONS Early multiple organ dysfunction following moderate-severe traumatic brain injury is common and independently impacts multiple domains (mortality, function, and disability) over the year following injury. Further research is necessary to understand underlying mechanisms, improve early recognition, and optimize management strategies.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | - Nancy Temkin
- Department of Neurosurgery, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH
| | | | - Fred K. Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Daniel T. Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC
- Department of Neurosurgery, Duke University, Durham, NC
- Department of Neurology, Duke University, Durham, NC
| | | | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC
| | - Michael L. James
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Neurology, Duke University, Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Raquel Bartz
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, Durham, NC
- Critical Care and Perioperative Population Health Research (CAPER) Unit, Department of Anesthesiology, Duke University. Durham, NC
- Department of Population Health Sciences, Duke University, Durham, NC
| | | | - Amy J. Markowitz
- Brain and Spinal Injury Center, University of California at San Francisco, San Francisco, CA
| | - Monica S. Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Huang M, Gedansky A, Hassett CE, Price C, Fan TH, Stephens RS, Nyquist P, Uchino K, Cho SM. Pathophysiology of Brain Injury and Neurological Outcome in Acute Respiratory Distress Syndrome: A Scoping Review of Preclinical to Clinical Studies. Neurocrit Care 2021; 35:518-527. [PMID: 34297332 PMCID: PMC8299740 DOI: 10.1007/s12028-021-01309-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/21/2021] [Indexed: 02/05/2023]
Abstract
Acute respiratory distress syndrome (ARDS) has been associated with secondary acute brain injury (ABI). However, there is sparse literature on the mechanism of lung-mediated brain injury and prevalence of ARDS-associated secondary ABI. We aimed to review and elucidate potential mechanisms of ARDS-mediated ABI from preclinical models and assess the prevalence of ABI and neurological outcome in ARDS with clinical studies. We conducted a systematic search of PubMed and five other databases reporting ABI and ARDS through July 6, 2020 and included studies with ABI and neurological outcome occurring after ARDS. We found 38 studies (10 preclinical studies with 143 animals; 28 clinical studies with 1175 patients) encompassing 9 animal studies (n = 143), 1 in vitro study, 12 studies on neurocognitive outcomes (n = 797), 2 clinical observational studies (n = 126), 1 neuroimaging study (n = 15), and 13 clinical case series/reports (n = 15). Six ARDS animal studies demonstrated evidence of neuroinflammation and neuronal damage within the hippocampus. Five animal studies demonstrated altered cerebral blood flow and increased intracranial pressure with the use of lung-protective mechanical ventilation. High frequency of ARDS-associated secondary ABI or poor neurological outcome was observed ranging 82-86% in clinical observational studies. Of the clinically reported ABIs (median age 49 years, 46% men), the most common injury was hemorrhagic stroke (25%), followed by hypoxic ischemic brain injury (22%), diffuse cerebral edema (11%), and ischemic stroke (8%). Cognitive impairment in patients with ARDS (n = 797) was observed in 87% (range 73-100%) at discharge, 36% (range 32-37%) at 6 months, and 30% (range 25-45%) at 1 year. Mechanisms of ARDS-associated secondary ABI include primary hypoxic ischemic injury from hypoxic respiratory failure, secondary injury, such as lung injury induced neuroinflammation, and increased intracranial pressure from ARDS lung-protective mechanical ventilation strategy. In summary, paucity of clinical data exists on the prevalence of ABI in patients with ARDS. Hemorrhagic stroke and hypoxic ischemic brain injury were commonly observed. Persistent cognitive impairment was highly prevalent in patients with ARDS.
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Affiliation(s)
- Merry Huang
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Aron Gedansky
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Catherine E Hassett
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Carrie Price
- Albert S. Cook Library, Towson University, Towson, MD, USA
| | - Tracey H Fan
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - R Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Nyquist
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 N. Wolfe Street, Phipps 455, Baltimore, MD, USA.
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23
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Shin SS, Hwang M, Diaz-Arrastia R, Kilbaugh TJ. Inhalational Gases for Neuroprotection in Traumatic Brain Injury. J Neurotrauma 2021; 38:2634-2651. [PMID: 33940933 PMCID: PMC8820834 DOI: 10.1089/neu.2021.0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite multiple prior pharmacological trials in traumatic brain injury (TBI), the search for an effective, safe, and practical treatment of these patients remains ongoing. Given the ease of delivery and rapid absorption into the systemic circulation, inhalational gases that have neuroprotective properties will be an invaluable resource in the clinical management of TBI patients. In this review, we perform a systematic review of both pre-clinical and clinical reports describing inhalational gas therapy in the setting of TBI. Hyperbaric oxygen, which has been investigated for many years, and some of the newest developments are reviewed. Also, promising new therapies such as hydrogen gas, hydrogen sulfide gas, and nitric oxide are discussed. Moreover, novel therapies such as xenon and argon gases and delivery methods using microbubbles are explored.
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Affiliation(s)
- Samuel S. Shin
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Misun Hwang
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Brain-Lung Conflicts and Patterns of Mechanical Ventilation. Crit Care Med 2021; 49:1200-1202. [PMID: 34135278 DOI: 10.1097/ccm.0000000000004957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Krishnamoorthy V, Komisarow JM, Laskowitz DT, Vavilala MS. Multiorgan Dysfunction After Severe Traumatic Brain Injury: Epidemiology, Mechanisms, and Clinical Management. Chest 2021; 160:956-964. [PMID: 33460623 PMCID: PMC8448997 DOI: 10.1016/j.chest.2021.01.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/10/2020] [Accepted: 01/07/2021] [Indexed: 01/20/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health problem and a major contributor to morbidity and mortality following multisystem trauma. Extracranial organ dysfunction is common after severe TBI and significantly impacts clinical care and outcomes following injury. Despite this, extracranial organ dysfunction remains an understudied topic compared with organ dysfunction in other critical care paradigms. In this review, we will: 1) summarize the epidemiology of extracranial multiorgan dysfunction following severe TBI; 2) examine relevant mechanisms that may be involved in the development of multi-organ dysfunction following severe TBI; and 3) discuss clinical management strategies to care for these complex patients.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, Chapel Hill, NC; Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC.
| | - Jordan M Komisarow
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Chapel Hill, NC; Department of Neurosurgery, Duke University, Chapel Hill, NC
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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26
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Yeung E, Miller M, Wung C, Behm R, Cagir B, Granet P. Possible Predictive Factor of Acute Respiratory Distress Syndrome Development After Mild Traumatic Brain Injury: A Single Rural Trauma Center Preliminary Study. Cureus 2021; 13:e16508. [PMID: 34430122 PMCID: PMC8374992 DOI: 10.7759/cureus.16508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Acute respiratory distress syndrome (ARDS) after mild traumatic brain injury (TBI) can be associated with significant morbidity and mortality. This study aimed to evaluate the potential predictive factors of ARDS development following mild TBI in trauma patients. Methods A retrospective chart review was done for adult trauma patients with mild TBI (GCS 13-15) requiring admission at our center from 2012 to 2020. Linear regression analysis and chi-square test were utilized to identify independent predictors of the association with ARDS in adults with mild TBI. Results A total of 784 mild TBI patients were admitted during the time of interest; 34 patients developed ARDS during their index hospitalization. Patients who had ARDS were more likely to have acute kidney injury (AKI; p < 0.0001), sepsis (p < 0.01), rib fractures (p < 0.05), use of anticoagulants (p < 0.001), deep vein thrombosis (p < 0.001), transfusion during the first 4four hours upon admission (p = 0.01), intravenous fluid (IVF) resuscitation during the first four hours (p <0.05), the first eight hours (p = 0.01), the first 12 hours (p = 0.03), and intubation upon the admission (p < 0.0001). ARDS associated with mild TBI demonstrated a statistically significant increase in mortality during the index hospitalization (p < 0.0001). Conclusion ARDS after mild TBI can be associated with significant morbidity and mortality. Key risk factors identified include AKI, sepsis, anticoagulant use, deep vein thrombosis (DVT), transfusion in the first four hours, IVF resuscitation in the first four, eight, and 12 hours, and intubation upon admission.
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Affiliation(s)
- Enoch Yeung
- Surgery, Guthrie Robert Packer Hospital, Sayre, USA
| | | | - Cynthia Wung
- Surgery, Guthrie Robert Packer Hospital, Sayre, USA
| | - Robert Behm
- Trauma/Critical Care, Guthrie Robert Packer Hospital, Sayre, USA
| | - Burt Cagir
- Colorectal Surgery, Guthrie Robert Packer Hospital, Sayre, USA
| | - Paul Granet
- Trauma/Surgical Critical Care, Guthrie Robert Packer Hospital, Sayre, USA
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27
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Incidence and Clinical Impact of Myocardial Injury Following Traumatic Brain Injury: A Pilot TRACK-TBI Study. J Neurosurg Anesthesiol 2021; 34:233-237. [PMID: 33901061 DOI: 10.1097/ana.0000000000000772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major global health problem. Little research has addressed extracranial organ dysfunction following TBI, particularly myocardial injury. Using a sensitive marker of myocardial injury-high sensitivity troponin (hsTn)-we examined the incidence of early myocardial injury following TBI and explored its association with neurological outcomes following moderate-severe TBI. METHODS We conducted a pilot cohort study of 133 adult (age above 17 y) subjects enrolled in the TRACK-TBI 18-center prospective cohort study. Descriptive statistics were used to examine the incidence of myocardial injury (defined as hsTn >99th percentile for a standardized reference population) across TBI severities, and to explore the association of myocardial injury with a 6-month extended Glasgow Outcome Score among patients with moderate-severe TBI. RESULTS The mean (SD) age of the participants was 44 (17) years, and 87 (65%) were male. Twenty-six patients (20%) developed myocardial injury following TBI; myocardial injury was present in 15% of mild TBI patients and 29% of moderate-severe TBI patients (P=0.13). Median (interquartile range) hsTn values were 3.8 ng/L (2.1, 9.0), 5.8 ng/L (4.5, 34.6), and 10.2 ng/L (3.0, 34.0) in mild, moderate, and severe TBI participants, respectively (P=0.04). Overall, 11% of participants with moderate-severe TBI and myocardial injury experienced a good outcome (6-mo extended Glasgow Outcome Score≥5) at 6 months, compared with 65% in the group that did not experience myocardial injury (P=0.01). CONCLUSIONS Myocardial injury is common following TBI, with a likely dose-response relationship with TBI severity. Early myocardial injury was associated with poor 6-month clinical outcomes following moderate-severe TBI.
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28
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Farhat A, Grigorian A, Farhat A, Chin TL, Donnelly M, Dolich M, Kuza CM, Lekawa M, Nahmias J. Injury and Mortality Profiles in Level II and III Trauma Centers. Am Surg 2021; 88:58-64. [PMID: 33775161 DOI: 10.1177/0003134820966290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND While the benefit of admission to trauma centers compared to non-trauma centers is well-documented and differences in outcomes between Level-I and Level-II trauma centers are well-studied, data on the differences in outcomes between Level-II trauma centers (L2TCs) and Level-III trauma centers (L3TCs) are scarce. OBJECTIVES We sought to compare mortality risk between patients admitted to L2TCs and L3TCs, hypothesizing no difference in mortality risk for patients treated at L3TCs compared to L2TCs. METHODS A retrospective analysis of the 2016 Trauma Quality Improvement Program (TQIP) database was performed. Patients aged 18+ years were divided into 2 groups, those treated at American College of Surgeons (ACS) verified L2TCs and L3TCs. RESULTS From 74,486 patients included in this study, 74,187 (99.6%) were treated at L2TCs and 299 (.4%) at L3TCs. Both groups had similar median injury severity scores (ISSs) (10 vs 10, P < .001); however, L2TCs had a higher mean ISS (14.6 vs 11.9). There was a higher mortality rate for L2TC patients (6.0% vs 1.7%, P = .002) but no difference in associated risk of mortality between the 2 groups (OR .46, CI .14-1.50, P = .199) after adjusting predictors of mortality. L2TC patients had a longer median length of stay (5.0 vs 3.5 days, P < .001). There was no difference in other outcomes including myocardial infarction (MI) and cerebrovascular accident (CVA) (P > .05). DISCUSSION Patients treated at L2TCs had a longer LOS compared to L3TCs. However, after controlling for covariates, there was no difference in associated mortality risk between L2TC and L3TC patients.
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Affiliation(s)
- Ali Farhat
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, CA, USA
| | - Ahmed Farhat
- Department of Surgery, University of California, Irvine, CA, USA
| | - Theresa L Chin
- Department of Surgery, University of California, Irvine, CA, USA
| | - Megan Donnelly
- Department of Surgery, University of California, Irvine, CA, USA
| | - Matthew Dolich
- Department of Surgery, University of California, Irvine, CA, USA
| | - Catherine M Kuza
- Department of Anesthesiology, 5116University of Southern California, Los Angeles, CA, USA
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, CA, USA
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29
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Kerr NA, de Rivero Vaccari JP, Weaver C, Dietrich WD, Ahmed T, Keane RW. Enoxaparin Attenuates Acute Lung Injury and Inflammasome Activation after Traumatic Brain Injury. J Neurotrauma 2021; 38:646-654. [PMID: 32669032 PMCID: PMC7898405 DOI: 10.1089/neu.2020.7257] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Traumatic brain injury (TBI) patients frequently develop cardiopulmonary system complications such as acute lung injury (ALI)/acute respiratory distress syndrome (ARDS). However, the mechanism by which TBI causes ALI/ARDS is not fully understood. Here, we used a severe TBI model to examine the effects of a low-molecular-weight heparin, enoxaparin, on inflammasome activation and lung injury damage. We investigated whether enoxaparin inhibits ALI and inflammasome signaling protein expression in the brain and lungs after TBI in mice. C57/BL6 mice were subjected to severe TBI and were treated with vehicle or 1 mg/kg of enoxaparin 30 min after injury. Lung and brain tissue were collected 24 h post-TBI and were analyzed by immunoblotting for expression of the inflammasome proteins, caspase-1 and interleukin (IL)-1β. In addition, lung tissue was collected for histological analysis to determine ALI scoring and neutrophil and macrophage infiltration post-injury. Our data show that severe TBI induces increased expression of inflammasome proteins caspase-1 and IL-1β in the brain and lungs of mice after injury. Treatment with enoxaparin attenuated inflammasome expression in the brain and lungs 24 h after injury. Enoxaparin significantly decreased ALI score as well as neutrophil and macrophage infiltration in lungs at 24 h after injury. This study demonstrates that enoxaparin attenuates ALI and inhibits inflammasome expression in the brain and lungs after TBI. These findings support the hypothesis that inhibition of the neural-respiratory inflammasome axis that is activated after TBI may have therapeutic potential.
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Affiliation(s)
- Nadine A. Kerr
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Cailey Weaver
- Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - W. Dalton Dietrich
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tahir Ahmed
- Pulmonary Division, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Robert W. Keane
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, Florida, USA
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30
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Parker BM, Menaker J, Berry CD, Tesoreiero RB, O'Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg 2020; 87:949-953. [PMID: 33295187 DOI: 10.1177/0003134820956360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
METHODS We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate. RESULTS 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C. CONCLUSION VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.
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Affiliation(s)
- Brandon M Parker
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jay Menaker
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Cherisse D Berry
- Department of Surgery, School of Medicine, New York University, New York, NY, USA
| | | | - James V O'Connor
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Deborah M Stein
- Department of Surgery, Univeristy of California, San Francisco, CA, USA
| | - Thomas M Scalea
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
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31
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Komisarow JM, Chen F, Vavilala MS, Laskowitz D, James ML, Krishnamoorthy V. Epidemiology and Outcomes of Acute Respiratory Distress Syndrome Following Isolated Severe Traumatic Brain Injury. J Intensive Care Med 2020; 37:68-74. [PMID: 33191844 DOI: 10.1177/0885066620972001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with traumatic brain injury (TBI) are at risk for extra-cranial complications, such as the acute respiratory distress syndrome (ARDS). We conducted an analysis of risk factors, mortality, and healthcare utilization associated with ARDS following isolated severe TBI. The National Trauma Data Bank (NTDB) dataset files from 2007-2014 were used to identify adult patients who suffered isolated [other body region-specific Abbreviated Injury Scale (AIS) < 3] severe TBI [admission total Glasgow Coma Scale (GCS) from 3 to 8 and head region-specific AIS >3]. In-hospital mortality was compared between patients who developed ARDS and those who did not. Utilization of healthcare resources (ICU length of stay, hospital length of stay, duration of mechanical ventilation, and frequency of tracheostomy and gastrostomy tube placement) was also examined. This retrospective cohort study included 38,213 patients with an overall ARDS occurrence of 7.5%. Younger age, admission tachycardia, pre-existing vascular and respiratory diseases, and pneumonia were associated with the development of ARDS. Compared to patients without ARDS, patients that developed ARDS experienced increased in-hospital mortality (OR 1.13, 95% CI 1.01-1.26), length of stay (p = <0.001), duration of mechanical ventilation (p = < 0.001), and placement of tracheostomy (OR 2.70, 95% CI 2.34-3.13) and gastrostomy (OR 2.42, 95% CI 2.06-2.84). After isolated severe TBI, ARDS is associated with increased mortality and healthcare utilization. Future studies should focus on both prevention and management strategies specific to TBI-associated ARDS.
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Affiliation(s)
| | - Fangyu Chen
- School of Medicine, 12277Duke University, Durham, NC, USA
| | - Monica S Vavilala
- Department of Anesthesiology, 7284University of Washington, Seattle, WA, USA
| | | | - Michael L James
- Department of Neurology, 12277Duke University, Durham, NC, USA.,Department of Anesthesiology, 12277Duke University, Durham, NC, USA
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32
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Theodore D, Mahanes D, Leite M. Oesophageal pressure-guided management of severe acute respiratory distress syndrome in a patient with intractable intracranial hypertension. BMJ Case Rep 2019; 12:12/11/e230723. [PMID: 31780614 DOI: 10.1136/bcr-2019-230723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of a young boy who sustained a traumatic brain injury (TBI) complicated by intractable intracranial hypertension and severe acute respiratory distress syndrome (ARDS) with hypercapnia. The coexisting pulmonary pathology significantly impacted intracranial pressure management. Oesophageal pressure manometry was used to guide ventilator and airway pressure management, allowing the team to optimise ARDS care while mitigating the risk of elevated intracranial pressure. While the literature describing the use of oesophageal pressure-guided ARDS management continues to evolve, there are no reported cases demonstrating use in patients with ARDS and intractable intracranial hypertension due to TBI.
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Affiliation(s)
- Danny Theodore
- Anesthesiology and Critical Care Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dea Mahanes
- Nerancy Neuro Intensive Care Unit, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Leite
- Department of Pulmonary Diagnostics and Respiratory Therapy, University of Virginia Health System, Charlottesville, Virginia, USA
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33
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Cole E, Gillespie S, Vulliamy P, Brohi K. Multiple organ dysfunction after trauma. Br J Surg 2019; 107:402-412. [PMID: 31691956 PMCID: PMC7078999 DOI: 10.1002/bjs.11361] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/02/2019] [Accepted: 08/13/2019] [Indexed: 01/31/2023]
Abstract
Background The nature of multiple organ dysfunction syndrome (MODS) after traumatic injury is evolving as resuscitation practices advance and more patients survive their injuries to reach critical care. The aim of this study was to characterize contemporary MODS subtypes in trauma critical care at a population level. Methods Adult patients admitted to major trauma centre critical care units were enrolled in this 4‐week point‐prevalence study. MODS was defined by a daily total Sequential Organ Failure Assessment (SOFA) score of more than 5. Hierarchical clustering of SOFA scores over time was used to identify MODS subtypes. Results Some 440 patients were enrolled, of whom 245 (55·7 per cent) developed MODS. MODS carried a high mortality rate (22·0 per cent versus 0·5 per cent in those without MODS; P < 0·001) and 24·0 per cent of deaths occurred within the first 48 h after injury. Three patterns of MODS were identified, all present on admission. Cluster 1 MODS resolved early with a median time to recovery of 4 days and a mortality rate of 14·4 per cent. Cluster 2 had a delayed recovery (median 13 days) and a mortality rate of 35 per cent. Cluster 3 had a prolonged recovery (median 25 days) and high associated mortality rate of 46 per cent. Multivariable analysis revealed distinct clinical associations for each form of MODS; 24‐hour crystalloid administration was associated strongly with cluster 1 (P = 0·009), traumatic brain injury with cluster 2 (P = 0·002) and admission shock severity with cluster 3 (P = 0·003). Conclusion Contemporary MODS has at least three distinct types based on patterns of severity and recovery. Further characterization of MODS subtypes and their underlying pathophysiology may lead to future opportunities for early stratification and targeted interventions.
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Affiliation(s)
- E Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - S Gillespie
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - P Vulliamy
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - K Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
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Kerr N, de Rivero Vaccari JP, Dietrich WD, Keane RW. Neural-respiratory inflammasome axis in traumatic brain injury. Exp Neurol 2019; 323:113080. [PMID: 31626746 DOI: 10.1016/j.expneurol.2019.113080] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/11/2019] [Accepted: 10/04/2019] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality. Approximately 20-25% of TBI subjects develop Acute Lung Injury (ALI), but the pathomechanisms of TBI-induced ALI remain poorly defined. Currently, mechanical ventilation is the only therapeutic intervention for TBI-induced lung injury. Our recent studies have shown that the inflammasome plays an important role in the systemic inflammatory response leading to lung injury-post TBI. Here, we outline the role of the extracellular vesicle (EV)-mediated inflammasome signaling in the etiology of TBI-induced ALI. Furthermore, we evaluate the efficacy of a low molecular weight heparin (Enoxaparin, a blocker of EV uptake) and a monoclonal antibody against apoptosis speck-like staining protein containing a caspase recruitment domain (anti-ASC) as therapeutics for TBI-induced lung injury. We demonstate that activation of an EV-mediated Neural-Respiratory Inflammasome Axis plays an essential role in TBI-induced lung injury and disruption of this axis has therapeutic potential as a treatment strategy.
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Affiliation(s)
- Nadine Kerr
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America
| | - Juan Pablo de Rivero Vaccari
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America
| | - W Dalton Dietrich
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America
| | - Robert W Keane
- Department of Neurological Surgery, University of Miami Miller School of Medicine, United States of America; Miami Project to Cure Paralysis, United States of America; Department of Physiology and Biophysics, University of Miami Miller School fo Medicine, 1600 NW10th Avenue, Miami, FL 33136, United States of America.
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Winkelmann M, Clausen JD, Graeff P, Schröter C, Zeckey C, Weber-Spickschen S, Mommsen P. Impact of Accidental Hypothermia on Pulmonary Complications in Multiply Injured Patients With Blunt Chest Trauma - A Matched-pair Analysis. In Vivo 2019; 33:1539-1545. [PMID: 31471402 DOI: 10.21873/invivo.11634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Blunt chest trauma is one of the major injuries in multiply injured patients and is associated with an increased risk of acute respiratory distress syndrome (ARDS) and ventilator-associated pneumonia (VAP). Accidental hypothermia is a common accompaniment of multiply injured patients. The objective of this study was to analyze the influence of accidental hypothermia on pulmonary complications in multiply injured patients with blunt chest trauma. PATIENTS AND METHODS Multiply injured patients [injury severity score (ISS) ≥16] with severe blunt chest trauma [abbreviated injury scale of the chest (AISchest) ≥3] were analyzed. Hypothermia was defined as body core temperature <35°C. The primary endpoint was the development of ARDS and VAP. Propensity score matching was performed. RESULTS Data were analyzed for 238 patients, with a median ISS of 26 (interquartile range=12). A total of 67 patients (28%) were hypothermic on admission. Hypothermic patients were injured more severely (median ISS 34 vs. 24, p<0.001) and had a higher transfusion requirement (p<0.001). Their mortality rate was consequently increased (10% vs. 1%, p=0.002); After propensity score matching, the mortality rate was still higher (10% vs. 2%, p=0.046). However, hypothermia was not an independent predictor of mortality. Hypothermic patients had to be ventilated longer (p=0.02). However, there were no differences in occurrence of ARDS and VAP. Hypothermia was not identified as an independent predictor of ARDS and VAP. CONCLUSION Among multiply injured patients with severe blunt chest trauma, accidental hypothermia is not an independent predictor of ARDS and VAP and is more likely to be an accompaniment of injury severity and hemorrhage.
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Affiliation(s)
| | | | - Pascal Graeff
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Christian Schröter
- Trauma Department, Hannover Medical School, Hannover, Germany.,Trauma Department, Wolfsburg Hospital, Wolfsburg, Germany
| | - Christian Zeckey
- Trauma Department, Hannover Medical School, Hannover, Germany.,Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University Munich, Munich, Germany
| | | | - Philipp Mommsen
- Trauma Department, Hannover Medical School, Hannover, Germany
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Dai Q, Wang S, Liu R, Wang H, Zheng J, Yu K. Risk factors for outcomes of acute respiratory distress syndrome patients: a retrospective study. J Thorac Dis 2019; 11:673-685. [PMID: 31019754 DOI: 10.21037/jtd.2019.02.84] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background The determination of risk factors for acute respiratory distress syndrome (ARDS) patients remains a challenge. Our study aims to explore the epidemiology and risk factors affecting outcomes of ARDS patients and provide a theoretical basis for patients' prognosis. Methods This retrospective study included 207 ARDS patients admitted to the general intensive care unit (ICU) in the Second Affiliated Hospital of Harbin Medical University from Jan 1st, 2016 to Jan 1st, 2017. The criteria were defined according to the Berlin Definition, and clinical data were collected from the medical record system. The mortality rate and duration of mechanical ventilation were compared in ARDS patients. Furthermore, logistic regression analysis was applied to screen clinically accessible risk factors for survival and duration of mechanical ventilation. Results The total mortality in ARDS patients was 39.13% (81/207) compared to 13.57% (151/1,113) in the whole ICU population. The period prevalence of mild, moderate and severe ARDS was 39.61% (82/207), 37.20% (77/207) and 23.19% (48/207), respectively. Logistic regression analysis showed that acute physiology and chronic health evaluation II (APACHE II) score (OR 3.4316; 95% CI: 1.3130-8.9686; P=0.0119), number of organ failure (OR 3.4928; 95% CI: 1.9775-6.1693; P<0.0001), mean arterial pressure (MAP) (OR 5.1049; 95% CI: 1.8317-14.2274; P=0.0018), driving pressure (OR 6.0017; 95% CI: 2.1746-16.5641; P=0.0005) and lactate level (OR 4.0754; 95% CI: 1.6114-10.3068; P=0.0030) were influence factors for survival; severity of ARDS (OR 1.6715; 95% CI: 1.0307-2.7108; P=0.0373), ventilator-associated pneumonia (VAP) (OR 7.3746; 95% CI: 2.9799-18.2505; P<0.0001) and transfusion history (OR 2.2822; 95% CI: 1.0462-4.9783; P=0.0381) were influence factors for duration of mechanical ventilation. Conclusions Higher APACHE II score, more organ failures, lower MAP, higher driving pressure and higher lactate level are risk factors for survival. Higher severity of ARDS, VAP and transfusion history are risk factors for prolonged duration of mechanical ventilation. Application of these parameters would enable intensivists to treat their patients more precisely and comprehensively.
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Affiliation(s)
- Qingqing Dai
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Sicong Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Ruijin Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, China
| | - Hongliang Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Junbo Zheng
- Department of Critical Care Medicine, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Kaijiang Yu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, China
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Kerr NA, de Rivero Vaccari JP, Umland O, Bullock MR, Conner GE, Dietrich WD, Keane RW. Human Lung Cell Pyroptosis Following Traumatic Brain Injury. Cells 2019; 8:E69. [PMID: 30669285 PMCID: PMC6356886 DOI: 10.3390/cells8010069] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/09/2019] [Accepted: 01/15/2019] [Indexed: 01/08/2023] Open
Abstract
Approximately 30% of traumatic brain injured patients suffer from acute lung injury or acute respiratory distress syndrome. Our previous work revealed that extracellular vesicle (EV)-mediated inflammasome signaling plays a crucial role in the pathophysiology of traumatic brain injury (TBI)-induced lung injury. Here, serum-derived EVs from severe TBI patients were analyzed for particle size, concentration, origin, and levels of the inflammasome component, an apoptosis-associated speck-like protein containing a caspase-recruiting domain (ASC). Serum ASC levels were analyzed from EV obtained from patients that presented lung injury after TBI and compared them to EV obtained from patients that did not show any signs of lung injury. EVs were co-cultured with lung human microvascular endothelial cells (HMVEC-L) to evaluate inflammasome activation and endothelial cell pyroptosis. TBI patients had a significant increase in the number of serum-derived EVs and levels of ASC. Severe TBI patients with lung injury had a significantly higher level of ASC in serum and serum-derived EVs compared to individuals without lung injury. Only EVs isolated from head trauma patients with gunshot wounds were of neural origin. Delivery of serum-derived EVs to HMVEC-L activated the inflammasome and resulted in endothelial cell pyroptosis. Thus, serum-derived EVs and inflammasome proteins play a critical role in the pathogenesis of TBI-induced lung injury, supporting activation of an EV-mediated neural-respiratory inflammasome axis in TBI-induced lung injury.
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Affiliation(s)
- Nadine A Kerr
- Department of Neurological Surgery, University of Miami, Miami, FL 33136, USA.
| | | | - Oliver Umland
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA.
| | - M Ross Bullock
- Department of Neurological Surgery, University of Miami, Miami, FL 33136, USA.
| | - Gregory E Conner
- Department of Cell Biology, University of Miami, Miami, FL 33136, USA.
| | - W Dalton Dietrich
- Department of Neurological Surgery, University of Miami, Miami, FL 33136, USA.
| | - Robert W Keane
- Department of Physiology and Biophysics, University of Miami School of Medicine, 1600 NW 10th Ave. RMSB 5054, Miami, FL 33136, USA.
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Kogan A, Segel M, Ram E, Raanani E, Peled-Potashnik Y, Levin S, Sternik L. Acute Respiratory Distress Syndrome following Cardiac Surgery: Comparison of the American-European Consensus Conference Definition versus the Berlin Definition. Respiration 2019; 97:518-524. [DOI: 10.1159/000495511] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 11/15/2018] [Indexed: 01/02/2023] Open
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Chen H, Zhou J, Lin YQ, Zhou JX, Yu RG. Intracranial pressure responsiveness to positive end-expiratory pressure in different respiratory mechanics: a preliminary experimental study in pigs. BMC Neurol 2018; 18:183. [PMID: 30396336 PMCID: PMC6217765 DOI: 10.1186/s12883-018-1191-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 10/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Respiratory mechanics affects the effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP). Respiratory mechanics of the lung and the chest wall was not differentiated in previous studies. In the present study, we investigated the influence of the following possible determinants of ICP responsiveness to PEEP: chest wall elastance (ECW), lung elastance (EL), and baseline ICP. Methods Eight healthy Bama miniature pigs were studied. The increase of EL was induced by instillation of hydrochloride, and the increase of ECW was induced by strapping the animals’ chest wall and abdomen. A balloon-tipped catheter was placed intracranially for inducing intracranial hypertension. Six experimental conditions were investigated in sequence: 1) Normal; 2) Stiff Chest Wall; 3) Lung Injury; 4) Lung Injury + Stiff Chest Wall; 5) Lung Injury + Stiff Chest Wall + Intracranial Hypertension and 6) Lung Injury + Intracranial Hypertension. PEEP was gradually increased in a 5 cm H2O interval from 5 to 25 cm H2O in each condition. Blood pressure, central venous pressure, ICP, airway pressure and esophageal pressure were measured. Results Hydrochloride instillation significantly increased EL in conditions with lung injury. ECW significantly increased in the conditions with chest wall and abdomen strapping (all p < 0.05). ICP significantly increased with increments of PEEP in all non-intracranial hypertension conditions (p < 0.001). The greatest cumulative increase in ICP was observed in the Stiff Chest Wall condition (6 [5.3, 6.8] mm Hg), while the lowest cumulative increase in ICP was observed in the Lung Injury condition (2 [1.3, 3.8] mm Hg). ICP significantly decreased when PEEP was increased in the intracranial hypertension conditions (p < 0.001). There was no significant difference in cumulative ICP change between the two intracranial hypertension conditions (p = 0.924). Conclusions Different respiratory mechanics models can be established via hydrochloride induced lung injury and chest wall and abdominal strapping. The effect of PEEP on ICP is determined by respiratory mechanics in pigs with normal ICP. However, the responsiveness of ICP to PEEP is independent of respiratory mechanics when there is intracranial hypertension.
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Affiliation(s)
- Han Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China.
| | - Jing Zhou
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Yi-Qin Lin
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
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Bakhsheshian J, Ding L, Tang A, Wen T, Patel A, Strickland BA, Rennert RC, Amar A, Gruen P, Giannotta S, Mack WJ, Attenello FJ. Safety-Net Hospitals Have Higher Complication and Mortality Rates in the Neurosurgical Management of Traumatic Brain Injuries. World Neurosurg 2018; 119:e284-e293. [DOI: 10.1016/j.wneu.2018.07.134] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 10/28/2022]
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Chen H, Chen K, Xu JQ, Zhang YR, Yu RG, Zhou JX. Intracranial pressure responsiveness to positive end-expiratory pressure is influenced by chest wall elastance: a physiological study in patients with aneurysmal subarachnoid hemorrhage. BMC Neurol 2018; 18:124. [PMID: 30143022 PMCID: PMC6108121 DOI: 10.1186/s12883-018-1132-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/20/2018] [Indexed: 12/18/2022] Open
Abstract
Background Respiratory system elastance (ERS) is an important determinant of the responsiveness of intracranial pressure (ICP) to positive end-expiratory pressure (PEEP). However, lung elastance (EL) and chest wall elastance (ECW) were not differentiated in previous studies. We tested the hypothesis that patients with high ECW or a high ECW/ERS ratio have greater ICP responsiveness to PEEP. Methods An esophageal balloon catheter was placed to measure esophageal pressure. PEEP was increased from 5 to 15 cmH2O. Airway pressure and esophageal pressure were measured and EL, ECW and ERS were calculated at the two PEEP levels. Patients were classified into either an ICP responder group or a non-responder group based on whether the change of ICP after PEEP adjustment was greater than or less than the median of the overall study population. Results The magnitude of the increase in esophageal pressure (median [interquartile range]) at end-expiratory occlusion was significantly increased in the responder group compared with that in the non-responder group (4.1 [2.7–4.1] versus 2.7 [0.0–2.7] cmH2O, p = 0.033) after PEEP adjustment. ECW and the ECW/ERS ratio were significantly higher in ICP responders than in non-responders at both low PEEP (p = 0.021 and 0.017) and high PEEP (p = 0.011 and 0.025) levels. No significant differences in ERS and EL were noted between the two groups at both PEEP levels. Conclusions Patients with greater ICP responsiveness to increased PEEP exhibit higher ECW and a higher ECW/ERS ratio, suggesting the importance of ECW monitoring. Electronic supplementary material The online version of this article (10.1186/s12883-018-1132-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing, China.,Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Kai Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Jing-Qing Xu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Ying-Rui Zhang
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing, China.
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Is There a Relationship Between Optimal Cerebral Perfusion Pressure-Guided Management and PaO 2/FiO 2 Ratio After Severe Traumatic Brain Injury? ACTA NEUROCHIRURGICA. SUPPLEMENT 2018. [PMID: 29492533 DOI: 10.1007/978-3-319-65798-1_13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Severe traumatic brain injury (TBI) management has been associated with adult respiratory distress syndrome (ARDS) in previous literature. We aimed to investigate the relationships between optimal CPP-guided management, ventilation parameters over time and outcome after severe TBI. MATERIALS AND METHODS We performed retrospective analysis of recorded data from 38 patients admitted to the NCCU after severe TBI, managed with optimal cerebral perfusion pressure (CPPopt)-guided therapy, calculated using pressure reactivity index (PRx). All patients were sedated and ventilated with lung protective criteria (Peep > 5, tidal volume 6-8 ml/kg and airway pressure < 30 cmH2O). RESULTS Daily mean CPPopt varied between a minimum of 84 mmHg and a maximum of 91 mmHg with an all period mean value of 88 mmHg. The mean value for the difference between CPP and CPPopt was -1.9 mmHg. Daily mean P/F ratio decreased and varied between 253 and 387 with an all-period mean of 294 mmHg. During the 10 days of recording data, five patients (13%) developed criteria of severe ARDS, but only two patients died due to severe ARDS (5%). PaO2/FiO2 (P/F) ratio did not correlate with CPPopt, but showed a strong correlation with tidal volume (p = 0.000) and driving pressure (p = 0.000). CONCLUSIONS Although CPPopt-guided therapy may induce a decrease in P/F ratio over time during the first 10 days, we could not find an association with worst outcome, which may be influenced by lung protective ventilation strategies and preservation of cerebral autoregulation.
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Abstract
BACKGROUND Increased cerebral perfusion pressure (CPP)>70 mmHg has been associated with acute respiratory distress syndrome (ARDS) after traumatic brain injury (TBI). Since this reported association, significant changes in ventilation strategies and fluid management have been accepted as routine critical care. Recently, individualized perfusion targets using autoregulation monitoring suggest CPP titration>70 mmHg. Given these clinical advances, the association between ARDS and increased CPP requires further delineation. OBJECTIVE To determine the association between ARDS and increased CPP after TBI. METHODS We conducted a single-center historical cohort study investigating the association of increased CPP and ARDS after TBI. We collected demographic data and physiologic data for CPP, intracranial pressure, mechanical ventilation, cumulative fluid balance and delta/driving pressure (ΔP). We collected outcomes measures pertaining to duration of ventilation, intensive care unit admission length, hospitalization length and 6-month neurological outcome. RESULTS In total, 113 patients with severe TBI and multimodal neuromonitoring were included. In total, 16 patients (14%) developed ARDS according to the Berlin definition. There was no difference in the mean CPP during the first 7 days of admission between patients who developed ARDS (74 mmHg SD 18 vs. 73 mmHg SD 18, p=0.86) versus those who did not. Patients who developed ARDS had a higher ΔP (15 mmHg [5] vs. 12 mmHg [4], p=0.016) and lower lung compliance (35 ml/cmH2O [10] vs. 49 ml/cmH2O [18], p=0.024) versus those who did not. CONCLUSION We did not observe an association between increased CPP and ARDS. Patients with ARDS had higher ΔP and lower lung compliance.
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Xu X, Zhi T, Chao H, Jiang K, Liu Y, Bao Z, Fan L, Wang D, Li Z, Liu N, Ji J. ERK1/2/mTOR/Stat3 pathway-mediated autophagy alleviates traumatic brain injury-induced acute lung injury. Biochim Biophys Acta Mol Basis Dis 2018; 1864:1663-1674. [PMID: 29466698 DOI: 10.1016/j.bbadis.2018.02.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 01/21/2018] [Accepted: 02/15/2018] [Indexed: 01/06/2023]
Abstract
Acute lung injury (ALI) is one of several complications in patients with traumatic brain injury (TBI). Autophagy is a primary homeostatic process that promotes cell survival under stress. Accumulating evidence implicates autophagy in the pathogenesis of ALI under various conditions. However, the role of autophagy in TBI-induced ALI remains unknown. The aim of this study was to adjust autophagy with pharmacological agents to determine its functional significance in TBI-induced ALI. Rats were preconditioned with autophagy promoter rapamycin or inhibitor 3-methyladenine before they were challenged with TBI. Extracellular signal-regulated kinase 1/2 (ERK1/2) inhibitor U0126, mechanistic target of rapamycin (mTOR) inhibitor rapamycin, and signal transducer and activator of transcription 3 (Stat3) inhibitor S31-201 were used to test the role of ERK1/2/mTOR/Stat3 signaling pathway in regulating autophagy. Autophagy is activated in lung tissues after TBI. Enhancement of autophagy suppressed apoptosis, inflammation and oxidative stress in lung tissues, which were activated after TBI, whereas inhibition of autophagy aggravated these critical pathological changes. Autophagy also improved TBI-induced impairment in pulmonary barrier function, oxygenation function and static compliance. Furthermore, TBI-induced autophagy was mediated by ERK1/2/mTOR/Stat3 pathway, which may serve to reduce ALI and improve pulmonary barrier function, oxygenation function and static compliance. These findings are important for the prevention and treatment of TBI-induced ALI.
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Affiliation(s)
- Xiupeng Xu
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Tongle Zhi
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Honglu Chao
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kuan Jiang
- Department of Neurosurgery, Yixing People's Hospital, Yixing, Jiangsu, China
| | - Yinlong Liu
- Department of Neurosurgery, Suzhou Municipal Hospital, Suzhou, Jiangsu, China
| | - Zhongyuan Bao
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Liang Fan
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Dong Wang
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zheng Li
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ning Liu
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Ji
- Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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Hui L, Zhang X, An X, Li J, Zang K, Shang F, Zhang C, Zhang G. Higher serum procalcitonin and IL-6 levels predict worse diagnosis for acute respiratory distress syndrome patients with multiple organ dysfunction. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2017; 10:7401-7407. [PMID: 31966582 PMCID: PMC6965210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/09/2017] [Indexed: 06/10/2023]
Abstract
AIMS To study the clinical significance and prognostic value of monitoring procalcitonin (PCT) and interleukin 6 (IL-6) levels in acute respiratory distress syndrome (ARDS) patients with multiple organ dysfunction (MODS). METHODS We enrolled 24 ARDS patients with MODS (ARDS+MODS group), 18 patients with ARDS but without MODS (ARDS group), and 55 patients with MODS but without ARDS as controls (control group). We detected the oxygenation index, serum PCT, IL-6, C-reactive protein (CRP) and white blood cell count (WBC) values of the patients after 1, 7, 14, 21 and 28 days of hospitalization in all three groups; we also analyzed the receiver operating characteristic (ROC) curves of PCT, CRP, WBC and (or) IL-6 in the patients in the ARDS+MODS group. RESULTS The serum PCT and IL-6 levels in the ARDS+MODS group were significantly higher than those in the ARDS and MODS groups (P<0.01). The PCT and IL-6 levels increased with elevated ARDS illness severity (P<0.01); the sensitivity of PCT and IL-6 was high in all groups, but the specificity was low. Moreover, the PCT and IL-6 values were closely associated with patient survival. The lower PCT and IL-6 values indicated the higher survival rate. The PCT and IL-6 combined prophetic sensitivity of MODS complicated with ARDS area under the ROC curve was 0.911; thus, the index of PCT combined with IL-6 was the highest sensitive biological marker for the predicted occurrence of MODS with ARDS. CONCLUSIONS The serum PCT and IL-6 levels were significant for the diagnosis of ARDS patients with MODS, and the serum levels of PCT and IL-6 were associated with the severity of MODS with ARDS. Combined monitoring of PCT and IL-6 values and their dynamic changes is helpful for detecting the incidence of early ARDS in patients with MODS, and the index can predict whether ARDS will occur. The combined assessment of PCT and IL-6 can predict the prognosis of ARDS patients with MODS.
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Affiliation(s)
- Liangliang Hui
- ICU of The First People’s Hospital of Huaian, Nanjing Medical UniversityHuaian 223300, Jiangsu, China
| | - Xiangcheng Zhang
- ICU of The First People’s Hospital of Huaian, Nanjing Medical UniversityHuaian 223300, Jiangsu, China
| | - Xusheng An
- ICU of The First People’s Hospital of Huaian, Nanjing Medical UniversityHuaian 223300, Jiangsu, China
| | - Jinfang Li
- ICU of The First People’s Hospital of Huaian, Nanjing Medical UniversityHuaian 223300, Jiangsu, China
| | - Kui Zang
- ICU of The First People’s Hospital of Huaian, Nanjing Medical UniversityHuaian 223300, Jiangsu, China
| | - Futai Shang
- ICU of The First People’s Hospital of Huaian, Nanjing Medical UniversityHuaian 223300, Jiangsu, China
| | - Chongming Zhang
- ICU of The First Affiliated Hospital of Nanjing Medical UniversityNanjing 210029, Jiangsu, China
| | - Guoxin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical UniversityNanjing 210029, Jiangsu, China
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Boone MD, Jinadasa SP, Mueller A, Shaefi S, Kasper EM, Hanafy KA, O'Gara BP, Talmor DS. The Effect of Positive End-Expiratory Pressure on Intracranial Pressure and Cerebral Hemodynamics. Neurocrit Care 2017; 26:174-181. [PMID: 27848125 PMCID: PMC6613349 DOI: 10.1007/s12028-016-0328-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lung protective ventilation has not been evaluated in patients with brain injury. It is unclear whether applying positive end-expiratory pressure (PEEP) adversely affects intracranial pressure (ICP) and cerebral perfusion pressure (CPP). We aimed to evaluate the effect of PEEP on ICP and CPP in a large population of patients with acute brain injury and varying categories of acute lung injury, defined by PaO2/FiO2. METHOD Retrospective data were collected from 341 patients with severe acute brain injury admitted to the ICU between 2008 and 2015. These patients experienced a total of 28,644 paired PEEP and ICP observations. Demographic, hemodynamic, physiologic, and ventilator data at the time of the paired PEEP and ICP observations were recorded. RESULTS In the adjusted analysis, a statistically significant relationship between PEEP and ICP and PEEP and CPP was found only among observations occurring during periods of severe lung injury. For every centimeter H2O increase in PEEP, there was a 0.31 mmHg increase in ICP (p = 0.04; 95 % CI [0.07, 0.54]) and a 0.85 mmHg decrease in CPP (p = 0.02; 95 % CI [-1.48, -0.22]). CONCLUSION Our results suggest that PEEP can be applied safely in patients with acute brain injury as it does not have a clinically significant effect on ICP or CPP. Further prospective studies are required to assess the safety of applying a lung protective ventilation strategy in brain-injured patients with lung injury.
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Affiliation(s)
- Myles D Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Sayuri P Jinadasa
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Khalid A Hanafy
- Department of Neurology, Division of Neurocritical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Brian P O'Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
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Jin Z, Suen KC, Ma D. Perioperative "remote" acute lung injury: recent update. J Biomed Res 2017; 31:197-212. [PMID: 28808222 PMCID: PMC5460608 DOI: 10.7555/jbr.31.20160053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/16/2016] [Indexed: 01/21/2023] Open
Abstract
Perioperative acute lung injury (ALI) is a syndrome characterised by hypoxia and chest radiograph changes. It is a serious post-operative complication, associated with considerable mortality and morbidity. In addition to mechanical ventilation, remote organ insult could also trigger systemic responses which induce ALI. Currently, there are limited treatment options available beyond conservative respiratory support. However, increasing understanding of the pathophysiology of ALI and the biochemical pathways involved will aid the development of novel treatments and help to improve patient outcome as well as to reduce cost to the health service. In this review we will discuss the epidemiology of peri-operative ALI; the cellular and molecular mechanisms involved on the pathological process; the clinical considerations in preventing and managing perioperative ALI and the potential future treatment options.
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Affiliation(s)
- Zhaosheng Jin
- Anaesthetics, Pain Medicine and intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London SW10 9NH, UK
| | - Ka Chun Suen
- Anaesthetics, Pain Medicine and intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London SW10 9NH, UK
| | - Daqing Ma
- Anaesthetics, Pain Medicine and intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London SW10 9NH, UK
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Cerebral oxidative metabolism failure in traumatic brain injury: "Brain shock". J Crit Care 2016; 37:230-233. [PMID: 27773372 DOI: 10.1016/j.jcrc.2016.09.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 12/19/2022]
Abstract
Shock is a systemic form of acute circulatory failure leading to cellular dysoxia and death. Such a state of aerobic metabolism failure also underlies neuronal cell death in severe traumatic brain injury. It is becoming increasingly recognized that ischemic hypoxia is not the sole mechanism and that multiple alternate cooperating mechanisms may be responsible for compromising neuronal oxidative metabolism. These different mechanisms can be usefully understood via analysis of the classic subdivisions of tissue hypoxia. This approach could lead to an alternative treatment paradigm toward cerebral oxygen metabolic rate targeting instead of the traditional targets of intracranial and perfusion pressures.
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