Intensive Care Treatment in Traumatic Brain Injury

Effect of different positive end expiratory pressure levels on optic nerve sheath diameter in patients with or without midline shift who are undergoing supratentorial craniotomy

PURPOSE

In general, high levels of PEEP application is avoided in patients undergoing craniotomy to prevent a rise in ICP. But that approach would increase the risk of secondary brain injury especially in hypoxemic patients. Because the optic nerve sheath is distensible, a rise in ICP is associated with an increase in the optic nerve sheath diameter (ONSD). The cutoff value for elevated ICP assessed by ONSD is between 5.6 and 6.3 mm. We aimed to evaluate the effect of different PEEP levels on ONSD and compare the effect of different PEEP levels in patients with and without intracranial midline shift.

METHODS

This prospective observational study was performed in aged 18-70 years, ASA I-III, 80 patients who were undergoing supratentorial craniotomy. After the induction of general anesthesia, the ONSD's were measured by the linear transducer from 3 mm below the globe at PEEP values of 0-5-10 cmH2O. The ONSD were compered between patients with (n = 7) and without midline shift (n = 73) at different PEEP values.

RESULTS

The increases in ONSD due to increase in PEEP level were determined (p < 0.001). No difference was found in the comparison of ONSD between patients with and without midline shift in different PEEP values (p = 0.329, 0.535, 0.410 respectively). But application of 10 cmH2O PEEP in patients with a midline shift increased the mean ONSD value to 5.73 mm. This value is roughly 0.1 mm higher than the lower limit of the ONSD cutoff value.

CONCLUSIONS

The ONSD in adults undergoing supratentorial tumor craniotomy, PEEP values up to 5 cmH2O, appears not to be associated with an ICP increase; however, the ONSD exceeded the cutoff for increased ICP when a PEEP of 10 cmH2O was applied in patients with midline shift.

The association between intracranial pressure and optic nerve sheath diameter on patients with head trauma

BACKGROUND

Although intracranial pressure (ICP) monitoring is the gold standard method for measuring intracranial pressure after traumatic brain injury, optic nerve sheath diameter (ONSD) measurement with ultrasound (US) is also used in the evaluation of ICP.

OBJECTIVE

To investigate the association between a series of OSND measurements by US and changes in clinical presentation of the patient.

METHODS

Prospective study including 162 patients with traumatic brain injury. Age, sex, cerebral CT findings, ONSD levels by US at minutes 0, 60, and 120, Glasgow Coma Scale (GCS) within same period, change of consciousness, treatment, and mortality data were reviewed. The association of ONSD levels with GCS, change of consciousness, treatment, and mortality was evaluated.

RESULTS

There was no difference in ONSD changes in the patients' sample within the period (p=0.326). ONSD significantly increased in patients who died (p<0.001), but not in those who survived (p=0.938). There was no significant change in ONSD of the patients who received anti-edema therapy (p=801), but significantly increased ONSD values were found in those who received anti-edema therapy (p=0.03). Patients without change of consciousness did not have any significant change in ONSD (p=0.672), but ONSD values increased in patients who consciousness became worse, and decreased in those who presented a recovery (respectively, p<0.001, p=0.002). A negative correlation was detected between ONSD values and GSC values measured at primary, secondary, and tertiary time periods (for all p<0.001).

CONCLUSIONS

ONSD follow-up may be useful to monitor ICP increase in patients with acute traumatic brain injury.

Continuous Endotracheal Tube Cuff Pressure Control Decreases Incidence of Ventilator-Associated Pneumonia in Patients with Traumatic Brain Injury

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common cause of morbidity and mortality in intensive care unit (ICU), and among the several preventative strategies described to reduce the incidence of VAP, the most important is the endotracheal tube cuff (ETC) pressure. The present study was conducted on 60 patients who required mechanical ventilation (MV) in the ICU with traumatic brain injury (TBI).

METHODS

The patients were randomized into two groups of 30, in which ETC pressure was regulated using a smart cuff manager (SCM) (Group II), or manual measurement approach (MMA) (Group I). Demographic data, MV duration, length of ICU stay and mortality rates were recorded. The clinical pulmonary infection scores (CPISs), C-reactive protein (CRP) values, and the fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP) values of the groups were compared at baseline, and at hours 48, 72 and 96.

RESULTS

In Group I, CPIS values significantly higher than Group II in 48th, 72nd and 96th hours (p < 0.05). In Group I, PEEP values and deep tracheal aspirate (DTA) culture growth rates significantly higher than Group II in 72nd and 96th hours (p < 0.05).

CONCLUSION

The continuous maintenance of ETC pressure using SCM reduced the incidence of VAP.

The Effect of Rutin on Experimental Traumatic Brain Injury and Edema in Rats

BACKGROUND/AIM

The aim of the study was to evaluate the effect of rutin, which is a vitamin P1 flavonoid with anti-inflammatory and anti-edema effects, on traumatic brain injury (TBI) and edema in rats.

MATERIALS AND METHODS

Rats were divided into 3 groups as sham group without brain trauma (SG), brain trauma without medication (BT) group and Rutin treated brain trauma (RBT) group. Fifty mg/kg rutin was administered to the RBT group once a day for three days. On the fourth day, rats were sacrificed. Extracted brain tissues were examined biochemically and histopathologically.

RESULTS

We found that the levels of malondialdehyde, nuclear factor-kappa B and tumor necrosis factor-alpha decreased, and those of total glutathione increased significantly. Furthermore, rutin administration reduced pyramidal neuron degeneration and poly-morpho-nuclear-leucocyte accumulation due to trauma in brain tissue, while eliminating edema.

CONCLUSION

Rutin might be effective in the treatment of TBI and TBI-related brain edema.

Non-neurologic organ dysfunction plays a major role in predicting outcomes in pediatric traumatic brain injury

BACKGROUND

Nonneurological organ dysfunction (NNOD) occurs after traumatic brain injury (TBI) and is associated with mortality. The aim of our study was to evaluate the prevalence of NNOD and its association with outcomes in pediatric patients with TBI. We hypothesized that NNOD is associated with worse outcomes in pediatric patients with severe TBI.

METHODS

We performed a 4-year (2013-16) analysis of our prospectively maintained TBI database. All patients (age < 18) with an isolated-severe TBI (head-abbreviated injury scale: AIS ≥ 3 & extracranial-AIS < 3) were included. NNOD was measured using the pediatric multiple organ dysfunction (P-MOD) score. Outcomes were in-hospital mortality, Glasgow Outcome Scale-Extended (GOS-E), and adverse discharge disposition: rehabilitation or skilled nursing facility (SNF). Regression analysis was performed.

RESULTS

We analyzed 292 patients. Mean age was 11 ± 6 years, 57% were male and the mortality rate was 18.1%. The incidence of NNOD was 35%. The most common dysfunctional organ system was the respiratory (25%) followed by the cardiovascular (12%). On regression analysis, the presence of at least one NNOD was independently associated with in-hospital mortality (OR 2.1 [1.7-2.9]; p < 0.01), low GOS-E (OR 1.8 [1.5-2.3]; p < 0.01), and SNF disposition (OR 1.7 [1.2-2.1]; p < 0.01).

CONCLUSION

NNOD develops in one of every three severe TBI pediatric patients and is independently associated with adverse outcomes. Identification of NNOD in pediatric TBI and focusing on management of NNOD could improve outcomes.

LEVEL OF EVIDENCE

III Prognostic.

Can Amantadine Ameliorate Neurocognitive Functions After Subarachnoid Haemorrhage? A Preliminary Study

OBJECTIVE

Aneurysmal subarachnoid haemorrhage (SAH) may have devastating effects on patients. Motor and neurocognitive impairments may arise depending on the location and grade of the SAH. Although the effects of amantadine on neurocognitive function after traumatic brain injury have been widely studied to the best of our knowledge, their effects on recovery from SAH in humans have not been studied. The present study aimed to evaluate how amantadine influences improvement in neurocognitive function in patients with aneurysmal SAH over a period of six months.

METHODS

This preliminary study included 12 patients with aneurysmal SAH who were admitted to the neurointensive care unit of Cerrahpasa Faculty of Medicine. Patients in Group A (n=5) received the standard treatment for SAH and amantadine for 30 days after admission, and those in Group C (n=7) received only the standard treatment. Neurocognitive function was evaluated using the Coma Recovery Scale-Revised and Disability Rating Scale on the first and fifth days and at the third and sixth months after admission. The primary endpoint of the present study was to compare the effects of amantadine in combination with the standard treatment to those of the standard treatment alone on the neurocognitive function of patients with SAH for over 6 months.

RESULTS

Compared to the standard treatment alone, amantadine administration with the standard treatment during the early period of SAH may improve recovery.

CONCLUSION

Amantadine along with the standard treatment can ameliorate neurocognitive function after SAH.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration

OBJECTIVES

The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h.

METHODS

This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared.

RESULTS

The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period.

CONCLUSION

The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration.