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Mohseni S, Forssten MP, Trivedi DJ, Buki A, Cao Y, Mohammad Ismail A, Ribeiro Jr MAF, Sarani B. Association between whole blood versus balanced component therapy and survival in isolated severe traumatic brain injury. Trauma Surg Acute Care Open 2025; 10:e001312. [PMID: 40406236 PMCID: PMC12096991 DOI: 10.1136/tsaco-2023-001312] [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] [Received: 11/16/2023] [Accepted: 05/08/2025] [Indexed: 05/24/2025] Open
Abstract
Background Whole blood transfusion (WBT) is associated with improved hemostasis and possibly mortality in patients with hemorrhagic shock after injury but there are no studies in patients with isolated severe traumatic brain injury (TBI). The objective of this investigation was to compare outcomes of balanced component therapy (BCT) versus WBT in patients with an isolated severe TBI. Methods Adult patients (≥18 years) registered in the Trauma Quality Improvement Program (2016-2019) who suffered a blunt isolated severe TBI (head Abbreviated Injury Score ≥3 in the head and ≤1 in the remaining body regions) and who received a BCT (1-2:1 packed red blood cell (PRBC):fresh frozen plasma and 1-2:1 PRBC:platelets) or WBT were eligible for inclusion. Patients were matched, based on the transfusion received, using propensity score matching. The primary outcome of interest was in-hospital mortality. Results A total of 217 patients received either WBT (n=82) or BCT (n=135). After propensity score matching, 50 matched pairs were analyzed. The rate of in-hospital mortality was significantly lower in the WBT compared with BCT group (43.1% vs 66.7%, p=0.025) corresponding to a relative risk (RR) reduction of 35% in in-hospital mortality (RR (CI 95%): 0.65 (0.43 to 0.97)). However, in subgroup analyses comparing those who were managed surgically and conservatively, this association only remained significant among patients who underwent neurosurgical intervention. Conclusions WBT in patients with severe isolated TBI is associated with better survival compared with BCT in patients who require neurosurgical intervention. Further investigation into this finding using an appropriately powered, prospective study design is warranted. Level of evidence Level III, therapeutic.
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Affiliation(s)
- Shahin Mohseni
- School of Medical Sciences, Orebro universitet, Orebro, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro universitet, Orebro, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Orebro, Sweden
| | - Dhanisha Jayesh Trivedi
- School of Medical Sciences, Orebro universitet, Orebro, Sweden
- Department of Neurosurgery, Orebro University Hospital, Orebro, Sweden
| | - Andras Buki
- School of Medical Sciences, Orebro universitet, Orebro, Sweden
- Department of Neurosurgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro universitet, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro universitet, Orebro, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Orebro, Sweden
| | | | - Babak Sarani
- Center of Trauma and Critical Care, The George Washington University, Washington, District of Columbia, USA
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Cottarelli A, Mamoon R, Ji R, Mao E, Boehme A, Kumar A, Song S, Allegra V, Sharma SV, Konofagou E, Spektor V, Guo J, Connolly ES, Sekar P, Woo D, Roh DJ. Low Hemoglobin Causes Hematoma Expansion and Poor Intracerebral Hemorrhage Outcomes. Stroke 2025; 56:1234-1242. [PMID: 40110594 PMCID: PMC12037308 DOI: 10.1161/strokeaha.124.049499] [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: 10/03/2024] [Revised: 01/23/2025] [Accepted: 02/17/2025] [Indexed: 03/22/2025]
Abstract
BACKGROUND Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH. METHODS A multicenter, prospective observational cohort study of 2997 patients with ICH enrolled between 2010 and 2016 was assessed. Patients with baseline hemoglobin measurements and serial computed tomography neuroimaging were included for analyses. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with hematoma expansion (≥33% and/or ≥6 mL growth) and poor long-term neurological outcomes (modified Rankin Scale score of 4-6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic versus nonanemic C57/BL6 mice, intergroup differences in ICH lesion volume, lesion volume changes, and early mortality were assessed. RESULTS Among 1190 ICH patients analyzed, the mean age was 61 years old, and 62% of the cohort were males. Lower baseline hemoglobin levels are associated with increased odds of hematoma expansion (adjusted odds ratio per -1 g/dL hemoglobin decrement, 1.10 [95% CI, 1.02-1.19]) and poor 3-month clinical outcomes (adjusted odds ratio per -1 g/dL hemoglobin decrement, 1.11 [95% CI, 1.03-1.21]). Similar relationships were seen with poor 6- and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, 24-hour lesion volumes, and greater mortality, as compared with nonanemic mice. CONCLUSIONS These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in hematoma expansion and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.
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Affiliation(s)
- Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Rayan Mamoon
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Robin Ji
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - Eric Mao
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Aditya Kumar
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sandy Song
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Valentina Allegra
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sabrina V. Sharma
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Elisa Konofagou
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - Vadim Spektor
- Department of Radiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jia Guo
- Department of Psychiatry, Columbia University, New York, NY
| | - E. Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Padmini Sekar
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Daniel Woo
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, OH
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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Wang J, Li XH, Yu JQ, Zheng RQ. Red blood cell transfusion strategy in traumatic brain injury patients: a systematic review and meta-analysis. Eur J Med Res 2025; 30:220. [PMID: 40170107 PMCID: PMC11959887 DOI: 10.1186/s40001-025-02498-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 03/23/2025] [Indexed: 04/03/2025] Open
Abstract
BACKGROUND The optimal red blood cell transfusion (RBCT) strategy for traumatic brain injury (TBI) patients remains a topic of debate. This systematic review and meta-analysis aimed to compare the outcomes of a liberal transfusion strategy versus a restrictive strategy in critically ill patients with TBI. METHODS PubMed, Web of Science, Embase, and Cochrane Library were searched from inception to November 17, 2024. We included randomized controlled trials (RCTs) of critically ill adult patients with TBI, reporting data on RBCT strategies. The outcomes included intensive care unit (ICU) mortality, long-term mortality, unfavorable functional outcomes, and the incidence of adverse events, such as transfused acute respiratory distress syndrome (TARDS) and venous thromboembolism. We also performed subgroup analyses comparing the association between disease severity and long-term mortality. This review was submitted to PROSPERO (Registration number: CRD42024558797). RESULTS In the results, our analysis revealed that compared to a restrictive transfusion strategy, a liberal strategy did not significantly reduce the risk of ICU mortality (RR: 0.74; 95% CI 0.28-1.91; P = 0.53) and long-term mortality (RR: 1.02; 95% CI 0.83-1.25; P = 0.87), but it was able to reduce the risk of unfavorable functional outcomes (RR: 0.90; 95% CI 0.82-0.98; P = 0.01), although there may be a false positive error. In addition, the liberal transfusion strategy was associated with a higher incidence of Transfused Acute Respiratory Distress Syndrome (TARDS) (RR: 1.78; 95% CI 1.06-2.98; P = 0.03). CONCLUSIONS In critically ill patients with TBI, a liberal RBCT strategy appears to improve functional outcomes but carries the risk of false positive errors. In addition, this strategy does not seem to improve survival and may increase the risk of TARDS. Despite this, there remains insufficient evidence to recommend either strategy in this population.
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Affiliation(s)
- Jing Wang
- Medical College, Yangzhou University, Department of Intensive Care Unit, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Xiang-Hui Li
- Department of Intensive Care Unit, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China
| | - Jiang-Quan Yu
- Department of Intensive Care Unit, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China.
| | - Rui-Qiang Zheng
- Department of Intensive Care Unit, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, No. 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China.
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Roh DJ, Liu M, Strobino K, Assuras S, Guzman VA, Levin B, Spitalnik SL, Rundek T, Wright CB, Elkind MSV, Gutierrez J. Relationships of hematocrit concentration with dementia from a multiethnic population-based study. Front Aging Neurosci 2025; 17:1543798. [PMID: 40026420 PMCID: PMC11868278 DOI: 10.3389/fnagi.2025.1543798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Accepted: 01/27/2025] [Indexed: 03/05/2025] Open
Abstract
Objective Red blood cell (RBC) concentration impacts cerebrovascular disease, yet it is unclear whether RBC concentrations relate to dementia risk, particularly in racially/ethnically diverse cohorts. We investigated whether RBC concentrations associate with incident dementia risk in a diverse population of stroke-free individuals and explored whether cerebral small vessel disease (CSVD) mediates this relationship. Methods A longitudinal observational analysis was performed using a population-based cohort of stroke-free, older adult participants (>50 years) from the Northern Manhattan Study (NOMAS) enrolled between 2003 and 2008. Participants received baseline hematocrit testing, MRI neuroimaging, and cognitive assessments at baseline and long-term follow-up. Associations of baseline hematocrit as a categorical variable (low, normal [reference], and high based on laboratory reference levels) with incident dementia were assessed using Cox models adjusting for relevant covariates. Separate analyses investigated whether MRI CSVD mediated these relationships. Results We studied 1,207 NOMAS participants (mean age 71 ± 9 years, 60% female, 66% Hispanic). Mean hematocrit was 41.2% (±3.8) with 16% of participants developing incident dementia. Lower hematocrit associated with increased dementia risk (adjusted hazard ratio 1.81 [1.01-3.23]) after adjusting for age, sex, race/ethnicity, education, APOE status, and comorbidities. High hematocrit was not associated with dementia risk. No interactions by sex or race/ethnicity were seen and baseline CSVD did not mediate relationships between hematocrit and dementia. Conclusion Low hematocrit associated with dementia risk in our diverse population cohort. However, our study limitations in laboratory and neuroimaging timing in addition to clarifying mechanistic underpinnings for our observations necessitates further work to clarify whether anemia can serve as a trackable, preventable/treatable risk factor for dementia.
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Affiliation(s)
- David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Minghua Liu
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Kevin Strobino
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Stephanie Assuras
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Vanessa A. Guzman
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Bonnie Levin
- Department of Neurology, University of Miami, Miami, FL, United States
| | - Steven L. Spitalnik
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miami, FL, United States
| | - Clinton B. Wright
- National Institute of Neurological Disorders and Stroke, Bethesda, MD, United States
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Jose Gutierrez
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
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Taleb C, Gouvea Bogossian E, Bittencour Rynkowski C, Møller K, Lormans P, Quintana Diaz M, Caricato A, Zattera L, Kurtz P, Meyfroidt G, Quintard H, Dias MC, Giacomucci A, Castelain C, Chabanne R, Marcos-Neira P, Bendel S, Alsheikhly AS, Elbahnasawy M, Gay S, D'Onofrio M, Popugaev KA, Markou N, Bouzat P, Vincent JL, Taccone FS. Liberal versus restrictive transfusion strategies in subarachnoid hemorrhage: a secondary analysis of the TRAIN study. Crit Care 2025; 29:67. [PMID: 39920710 PMCID: PMC11803982 DOI: 10.1186/s13054-025-05270-5] [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: 11/28/2024] [Accepted: 01/10/2025] [Indexed: 02/09/2025] Open
Abstract
BACKGROUND The optimal hemoglobin (Hb) threshold to trigger red blood cell transfusions (RBCT) in subarachnoid hemorrhage (SAH) patients is unclear. This study evaluated the impact of liberal versus restrictive transfusion strategies on neurological outcome in patients with SAH. METHODS This is a pre-planned secondary analysis of the "TRansfusion Strategies in Acute brain INjured Patients" (TRAIN) study. We included all SAH patients from the original study that were randomized to receive RBCT when Hb levels dropped below 9 g/dL (liberal group) or 7 g/dL (restrictive group). The primary outcome was an unfavorable neurological outcome at 180 days, defined by a Glasgow Outcome Scale Extended score of 1-5. RESULTS Of the 190 SAH patients in the trial, 188 (98.9%) had data available for the primary outcome, with 86 (45.3%) in the liberal group and 102 (53.6%) in the restrictive group. Patients in the liberal group were older than in the restrictive group, but otherwise had similar baseline characteristics. Patients in the liberal group received more RBCT and showed higher Hb levels over time. At 180 days, 57 (66.3%) patients in the liberal group and 78 (76.4%) in the restrictive group had unfavorable outcomes (risk ratio, RR 0.87; 95% confidence intervals, 95% CI 0.71-1.04). Patients in the liberal group had a significantly lower risk of cerebral ischemia (RR 0.63; 95% CI 0.41-0.97). In a multivariate analysis, randomization to the liberal group was associated with a lower risk of unfavorable outcome (RR 0.83, 95% CI 0.70-0.99). CONCLUSIONS A liberal transfusion strategy was not associated with a lower incidence of unfavorable outcome after SAH when compared to a restrictive strategy. However, in a multivariable analysis adjusted for confounders randomization to the liberal group was associated with lower risk of unfavorable outcome. The occurrence of cerebral ischemia was significantly lower in the liberal transfusion strategy group. TRIAL REGISTRATION ClinicalTrials.gov number-NCT02968654 registered on November 16th, 2016.
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Affiliation(s)
- Chahnez Taleb
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium.
| | - Carla Bittencour Rynkowski
- Intensive Care Unit of Cristo Redentor Hospital, Porto Alegre, Brazil
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Rigshospitalet - University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine-Anesthesiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Piet Lormans
- Department of Intensive Care, AZ Delta, Roeselaere, Belgium
| | - Manuel Quintana Diaz
- Department of Intensive Care Medicine, Hospital Universitario de La Paz, Madrid, Spain
| | - Anselmo Caricato
- Institute of Anesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | - Luigi Zattera
- Department of Anesthesiology and Intensive Care, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Pedro Kurtz
- Department of Intensive Care Medicine, DOr Institute of Research and Education, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Instituto Estadual do Cerebro Paulo Niemeyer, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Herve Quintard
- Division of Intensive Care Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Maria Celeste Dias
- Neurocritical Care Unit, Medical University Center (CUME), Porto, Portugal
| | - Angelo Giacomucci
- Anestesia and Intensive Care, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Charlotte Castelain
- Department of Anesthesia and Intensive Care Medicine, AZ Groeninge, Kortrijk, Belgium
| | - Russell Chabanne
- Neurocritical Care Unit, Neurosurgical and Neurointerventional Anesthesiology Clinic, Division of Anesthesiology, Critical Care and Peri-Operative Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Pilar Marcos-Neira
- Department of Intensive Care Medicine, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Stepani Bendel
- Department of Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | | | | | - Samuel Gay
- Intensive Care Unit, Centre Hospitalier Annecy-Genevois, Epagny Metz-Tessy, France
| | | | - Konstantin A Popugaev
- Department of Intensive Care, Sklifosovsky Research Institute of Emergency Medicine of the Moscow Healthcare Department, Moscow, Russia
- Department of Intensive Care, State Research Center, Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency, Moscow, Russia
| | | | - Pierre Bouzat
- Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Université Grenoble Alpes, Grenoble, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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Aziz N, Waqar U, Bukhari MM, Uzair M, Ahmed S, Naz H, Shamim MS. Blood transfusions in craniotomy for tumor resection: Incidence, risk factors, and outcomes. J Clin Neurosci 2025; 132:111009. [PMID: 39732040 DOI: 10.1016/j.jocn.2024.111009] [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] [Received: 11/25/2024] [Accepted: 12/21/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND Blood transfusions (BT) are often needed in neurosurgical procedures, especially craniotomies for tumor resections, due to risks of anemia, ischemic brain injury, and hemorrhage. However, BT may increase the risk of perioperative complications. This study aimed to determine the incidence, associated factors, and outcomes of BT in patients undergoing craniotomy for intracranial tumor resection. METHODS A retrospective cohort study was conducted using data from the National Surgical Quality Improvement Program (NSQIP). We included adult patients who underwent elective craniotomy for tumor resections from 2005 to 2021. Multivariable logistic regression was used to identify factors associated with BT as well as complications associated with receipt of BT within 30 days of surgery. RESULTS Among 40,883 patients, 3.65 % required BT. Significant factors associated with BT included age > 60 years (OR 1.28 [95 % CI 1.03-1.60]), female sex (1.41 [1.22-1.62]), underweight body mass index (BMI) (1.81 [1.27-2.57]), American Society of Anesthesiologists (ASA) class 3-4 (1.64 [1.39-1.95]), diabetes (1.23 [1.02-1.48]), chronic obstructive pulmonary disease (COPD) (1.64 [1.20-2.23]), preoperative anemia (2.84 [2.49-3.26]), bleeding disorders (2.37 [1.63-3.46]), preoperative transfusion (16.96 [8.09-35.56]), and meningioma indication (1.28 [1.03-1.60]). Patients with obesity were less likely to require BT (0.82 [0.69-0.98]). Patients requiring BT had higher odds of the following complications: prolonged ventilator use (OR 2.37 [1.60-3.50]), urinary tract infection (1.76 [1.03-3.00]), unplanned reoperation (1.49 [1.14-1.93]), prolonged length of stay (1.88 [1.60-2.21]), major morbidity (1.79 [1.32-2.44]), and all-cause mortality (1.34 [1.16-1.55]). CONCLUSION In craniotomy patients for tumor resection, factors associated with BT include age > 60, female sex, underweight BMI, ASA class 3-4, COPD, anemia, bleeding disorders, preoperative transfusion, and meningioma. BT is further associated with higher risks of major morbidity, mortality, longer hospital stays, and unplanned reoperations following surgery.
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Affiliation(s)
- Namrah Aziz
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Usama Waqar
- Medical College, Aga Khan University, Karachi, Pakistan
| | | | | | - Shaheer Ahmed
- Islamabad Medical & Dental College, Islamabad, Pakistan
| | - Huma Naz
- Gastroenterology and Surgery Service Line, Aga Khan University Hospital, Karachi, Pakistan
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de Carvalho Panzeri Carlotti AP, do Amaral VH, de Carvalho Canela Balzi AP, Johnston C, Regalio FA, Cardoso MF, Ferranti JF, Zamberlan P, Gilio AE, Malbouisson LMS, Delgado AF, de Carvalho WB. Management of severe traumatic brain injury in pediatric patients: an evidence-based approach. Neurol Sci 2025; 46:969-991. [PMID: 39476094 DOI: 10.1007/s10072-024-07849-2] [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] [Received: 07/15/2024] [Accepted: 10/20/2024] [Indexed: 01/28/2025]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of death and disability worldwide. The decision-making process in the management of severe TBI must be based on the best available evidence to minimize the occurrence of secondary brain injuries. However, healthcare approaches to managing TBI patients exhibit considerable variation. METHODS Over an 18-month period, a multidisciplinary panel consisting of medical doctors, physiotherapists, nutritional therapists, and nurses performed a comprehensive review on various subtopics concerning TBI. The panel identified primary questions to be addressed using the Population, Intervention, Control, and Outcome (PICO) format and applied the Evidence to Decision (EtD) framework criteria for evaluating interventions. Subsequently, the panel formulated recommendations for the management of severe TBI in children. RESULTS Fourteen evidence-based recommendations have been devised for the management of severe TBI in children, covering nine topics, including imaging studies, neuromonitoring, prophylactic anticonvulsant use, hyperosmolar therapy, sedation and analgesia, mechanical ventilation strategies, nutritional therapy, blood transfusion, and decompressive craniectomy. For each topic, the panel provided clinical recommendations and identified research priorities. CONCLUSIONS This review offers evidence-based strategies aimed to guide practitioners in the care of children who suffer from severe TBI.
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Affiliation(s)
- Ana Paula de Carvalho Panzeri Carlotti
- Division of Critical Care Medicine, Department of Pediatrics, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, Avenida dos Bandeirantes, 3900, Ribeirão Preto, SP, 14049-900, Brazil.
| | - Vivian Henriques do Amaral
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Ana Paula de Carvalho Canela Balzi
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cintia Johnston
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fabiane Allioti Regalio
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Maíra Freire Cardoso
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Juliana Ferreira Ferranti
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Patrícia Zamberlan
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Alfredo Elias Gilio
- Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luiz Marcelo Sá Malbouisson
- Surgical Pediatric Intensive Care Unit, Division of Anesthesiology, Instituto Central of Hospital das Clínicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Artur Figueiredo Delgado
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Werther Brunow de Carvalho
- Pediatric Critical Care Unit, Department of Pediatrics, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
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8
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Larcipretti ALL, Udoma-Udofa OC, Gomes FC, de Oliveira JS, Weba ETP, Cavalcante DVS, Dharaiya MK, Bannach MDA. Transfusion Practices in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med 2025:00003246-990000000-00445. [PMID: 39878558 DOI: 10.1097/ccm.0000000000006585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2025]
Abstract
OBJECTIVES Balancing oxygen requirements, neurologic outcomes, and systemic complications from transfusions in traumatic brain injury (TBI) patients is challenging. This review compares liberal and restrictive transfusion strategies in TBI patients. DATA SOURCES Electronic databases were searched from inception to October 2024. STUDY SELECTION We included randomized controlled trials comparing liberal and restrictive transfusion strategies in TBI patients. DATA EXTRACTION Data were extracted by two reviewers using predefined forms. DATA SYNTHESIS We included five studies with 1,533 patients: 769 (50.2%) in the liberal transfusion group and 764 (49.8%) in the restrictive group. There were no significant differences between groups favorable Glasgow Outcome Scale (risk ratio [RR], 1.16; 95% CI, 1.00-1.34), although a leave-one-out analysis demonstrated significance in this endpoint (RR, 1.24; 95% CI, 1.06-1.45). No significant difference was found regarding hospital mortality (RR, 0.98; 95% CI, 0.76-1.27), mortality at follow-up (RR, 1.03; 95% CI, 0.82-1.28), mortality in the ICU (RR, 1.00; 95% CI, 0.73-1.37), infection rates (RR, 1.08; 95% CI, 0.95-1.23), thromboembolic events (RR, 1.79; 95% CI, 0.74-4.31), hospital length of stay (LOS) (mean difference [MD], -1.45; 95% CI, -4.85 to 1.96), or ICU LOS (MD, -0.47; 95% CI, -3.84 to 2.91). The liberal transfusion strategy group had a significantly higher prevalence of acute respiratory distress syndrome (RR, 1.78; 95% CI, 1.06-2.98) and received more blood units per patient (MD, 2.62; 95% CI, 1.90-3.33). CONCLUSIONS Our findings suggest that a liberal transfusion strategy results in better neurologic outcomes than a restrictive approach. Future research should examine the complication profile and the effects of using a 9 g/dL threshold. We advocate for revising current guidelines to establish 9 g/dL as the standard threshold for transfusions in TBI patients.
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9
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Cottarelli A, Mamoon R, Ji R, Mao E, Boehme A, Kumar A, Song S, Allegra V, Sharma SV, Konofagou E, Spektor V, Guo J, Connolly ES, Sekar P, Woo D, Roh DJ. Low hemoglobin causes hematoma expansion and poor intracerebral hemorrhage outcomes. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.08.15.608155. [PMID: 39229082 PMCID: PMC11370400 DOI: 10.1101/2024.08.15.608155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Objectives Although lower hemoglobin levels associate with worse intracerebral hemorrhage (ICH) outcomes, causal drivers for this relationship remain unclear. We investigated the hypothesis that lower hemoglobin relates to increased hematoma expansion (HE) risk and poor outcomes using human observational data and assessed causal relationships using a translational murine model of anemia and ICH. Methods ICH patients with baseline hemoglobin measurements and serial CT neuroimaging enrolled between 2010-2016 to a multicenter, prospective observational cohort study were studied. Patients with systemic evidence of coagulopathy were excluded. Separate regression models assessed relationships of baseline hemoglobin with HE (≥33% and/or ≥6mL growth) and poor long-term neurological outcomes (modified Rankin Scale 4-6) after adjusting for relevant covariates. Using a murine collagenase ICH model with serial neuroimaging in anemic vs. non-anemic C57/BL6 mice, intergroup differences in ICH lesion volume, ICH volume changes, and early mortality were assessed. Results Among 1190 ICH patients analyzed, lower baseline hemoglobin levels associated with increased odds of HE (adjusted OR per -1g/dL hemoglobin decrement: 1.10 [1.02-1.19]) and poor 3-month clinical outcomes (adjusted OR per -1g/dL hemoglobin decrement: 1.11 [1.03-1.21]). Similar relationships were seen with poor 6 and 12-month outcomes. In our animal model, anemic mice had significantly greater ICH lesion expansion, final lesion volumes, and greater mortality, as compared to non-anemic mice. Conclusions These results, in a human cohort and a mouse model, provide novel evidence suggesting that anemia has causal roles in HE and poor ICH outcomes. Additional studies are required to clarify whether correcting anemia can improve these outcomes.
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Affiliation(s)
- Azzurra Cottarelli
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Rayan Mamoon
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Robin Ji
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - Eric Mao
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Aditya Kumar
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sandy Song
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Valentina Allegra
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Sabrina V. Sharma
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Elisa Konofagou
- Department of Biomedical Engineering, Columbia University, New York, NY
| | - Vadim Spektor
- Department of Radiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jia Guo
- Department of Psychiatry, Columbia University, New York, NY
| | - E. Sander Connolly
- Department of Neurological Surgery, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Padmini Sekar
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Daniel Woo
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, OH
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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10
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Roh DJ, Poyraz FC, Mao E, Shen Q, Kansara V, Cottarelli A, Song S, Nemkov T, Kumar A, Hudson KE, Ghoshal S, Park S, Agarwal S, Connolly ES, Claassen J, Kreuziger LB, Hod E, Yeatts S, Foster LD, Selim M. Anemia From Inflammation After Intracerebral Hemorrhage and Relationships With Outcome. J Am Heart Assoc 2024; 13:e035524. [PMID: 38979830 PMCID: PMC11292775 DOI: 10.1161/jaha.124.035524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Baseline anemia is associated with poor intracerebral hemorrhage (ICH) outcomes. However, underlying drivers for anemia and whether anemia development after ICH impacts clinical outcomes are unknown. We hypothesized that inflammation drives anemia development after ICH and assessed their relationship to outcomes. METHODS AND RESULTS Patients with serial hemoglobin and iron biomarker concentrations from the HIDEF (High-Dose Deferoxamine in Intracerebral Hemorrhage) trial were analyzed. Adjusted linear mixed models assessed laboratory changes over time. Of 42 patients, significant decrements in hemoglobin occurred with anemia increasing from 19% to 45% by day 5. Anemia of inflammation iron biomarker criteria was met in 88%. A separate cohort of 521 patients with ICH with more granular serial hemoglobin and long-term neurological outcome data was also investigated. Separate regression models assessed whether (1) systemic inflammatory response syndrome (SIRS) scores related to hemoglobin changes over time and (2) hemoglobin changes related to poor 90-day outcome. In this cohort, anemia prevalence increased from 30% to 71% within 2 days of admission yet persisted beyond this time. Elevated systemic inflammatory response syndrome was associated with greater hemoglobin decrements over time (adjusted parameter estimate: -0.27 [95% CI, -0.37 to -0.17]) and greater hemoglobin decrements were associated with poor outcomes (adjusted odds ratio per 1 g/dL increase, 0.76 [95% CI, 0.62-0.93]) independent to inflammation and ICH severity. CONCLUSIONS We identified novel findings that acute anemia development after ICH is common, rapid, and related to inflammation. Because anemia development is associated with poor outcomes, further work is required to clarify if anemia, or its underlying drivers, are modifiable treatment targets that can improve ICH outcomes. REGISTRATION https://www.clinicaltrials.gov Unique identifier: NCT01662895.
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Affiliation(s)
- David J. Roh
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Fernanda Carvalho Poyraz
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Eric Mao
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Qi Shen
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Vedant Kansara
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Azzurra Cottarelli
- Department of Pathology and Cell BiologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Sandy Song
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Travis Nemkov
- Department of Biochemistry and Molecular GeneticsUniversity of Colorado Denver Anschutz Medical CampusAuroraCOUSA
| | - Aditya Kumar
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Krystalyn E. Hudson
- Department of Pathology and Cell BiologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Shivani Ghoshal
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Soojin Park
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Sachin Agarwal
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Edward Sander Connolly
- Department of Neurological SurgeryVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Jan Claassen
- Department of NeurologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Lisa Baumann Kreuziger
- Versiti Blood Research InstituteVersiti; Department of MedicineDivision of Hematology and OncologyMedical College of WisconsinMilwaukeeWIUSA
| | - Eldad Hod
- Department of Pathology and Cell BiologyVagelos College of Physicians and SurgeonsColumbia UniversityNew York CityNYUSA
| | - Sharon Yeatts
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSCUSA
| | - Lydia D. Foster
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSCUSA
| | - Magdy Selim
- Department of NeurologyBeth Israel DeaconnessBostonMAUSA
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11
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Ma K, Bebawy JF. Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature. Anesth Analg 2024; 138:992-1002. [PMID: 38109853 DOI: 10.1213/ane.0000000000006772] [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: 12/20/2023]
Abstract
Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.
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Affiliation(s)
- Kan Ma
- From the Department of Anesthesiology and Pain Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - John F Bebawy
- Department of Anesthesiology and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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12
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Roh DJ, Murguia-Fuentes R, Gurel K, Khasiyev F, Rahman S, Bueno PP, Kozii K, Spagnolo-Allende AJ, Cottarelli A, Simonetto M, Ji R, Guo J, Spektor V, Hod EA, Burke DJ, Konofagou E, Rundek T, Wright CB, Marshall RS, Elkind MSV, Gutierrez J. Relationships of Hematocrit With Chronic Covert and Acute Symptomatic Lacunar Ischemic Lesions. Neurology 2024; 102:e207961. [PMID: 38165319 PMCID: PMC10870744 DOI: 10.1212/wnl.0000000000207961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/11/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Red blood cell (RBC) concentrations are known to associate with ischemic stroke. It is unclear whether RBC concentrations associate specifically with small vessel disease lacunar infarcts. We investigated the hypothesis that RBC concentrations associate with both chronic covert and acute symptomatic brain MRI lacunar infarcts. METHODS A cross-sectional observational analysis was performed across 2 cohorts with available hematocrit (as the assessment of RBC concentration exposure) and MRI outcome data. The primary setting was a population-based cohort of stroke-free, older adult (>50 years) participants from the Northern Manhattan Study (NOMAS) enrolled between 2003 and 2009. A second replication sample consisted of patients admitted with acute stroke and enrolled into the Columbia Stroke Registry (CSR) between 2005 and 2020. Associations of hematocrit with (1) chronic, covert lacunar infarcts and (2) symptomatic (i.e., acute) lacunar strokes were separately assessed from the NOMAS and CSR cohorts, respectively, using general additive models after adjusting for relevant covariates. RESULTS Of 1,218 NOMAS participants analyzed, 6% had chronic, covert lacunar infarcts. The association between hematocrit and these covert lacunar infarcts was U-shaped (χ2 = 9.21 for nonlinear associations; p = 0.03), with people with hematocrit extremes being more likely to have covert lacunar infarcts. Of the 1,489 CSR patients analyzed, 23% had acute lacunar strokes. In this sample, only the relationships of increased hematocrit concentrations and lacunar strokes were replicated (adjusted coefficient β = 0.020; SE = 0.009; p = 0.03). DISCUSSION We identified relationships of hematocrit with MRI lacunar infarcts in both stroke-free and ischemic stroke cohorts, respectively. The relationship between increased hematocrit concentrations with lacunar infarcts was replicated in both cohorts. Further studies are required to clarify the mechanisms behind the relationships of hematocrit with ischemic cerebral small vessel disease.
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Affiliation(s)
- David J Roh
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Ricardo Murguia-Fuentes
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Kursat Gurel
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Farid Khasiyev
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Salwa Rahman
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Pedro Paiva Bueno
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Khrystyna Kozii
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Antonio J Spagnolo-Allende
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Azzurra Cottarelli
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Marialaura Simonetto
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Robin Ji
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Jia Guo
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Vadim Spektor
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Eldad A Hod
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Devin J Burke
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Elisa Konofagou
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Tatjana Rundek
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Clinton B Wright
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Randolph S Marshall
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Mitchell S V Elkind
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
| | - Jose Gutierrez
- From the Departments of Neurology (D.J.R., K.G., S.R., P.P.B., K.K., A.J.S.-A., D.J.B., R.S.M., J. Gutierrez), Pathology and Cell Biology (A.C., E.A.H.), Biomedical Engineering (R.J., E.K.), Psychiatry (J. Guo), and Department of Radiology (V.S.), Vagelos College of Physicians and Surgeons, Columbia University, New York, NY; Department of Neurology (R.M.-F.), Louisiana State University Health Shreveport; Department of Neurology (F.K.), St. Louis University, MO; Department of Neurology (M.S.), Weill Cornell Medical Center, New York, NY; Department of Neurology (T.R.), University of Miami/Jackson Memorial Hospital, FL; National Institute of Neurological Disorders and Stroke (C.B.W.),, Bethesda, MD; and Department of Epidemiology (M.S.V.E.), Mailman School of Public Health, Columbia University, New York, NY
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13
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Filipovic MG, Luedi MM. Transfusion strategies in traumatic brain injury - A clinical debate. J Clin Anesth 2023; 90:111233. [PMID: 37633045 DOI: 10.1016/j.jclinane.2023.111233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/13/2023] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Mark G Filipovic
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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14
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Hou H, Pang L, Zhao L, Liu Z, Xing JH. Hemoglobin as a prognostic marker for neurological outcomes in post-cardiac arrest patients: a meta-analysis. Sci Rep 2023; 13:18531. [PMID: 37898729 PMCID: PMC10613227 DOI: 10.1038/s41598-023-45818-5] [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] [Received: 08/26/2023] [Accepted: 10/24/2023] [Indexed: 10/30/2023] Open
Abstract
The aim of this study was to investigate the relationship between serum level of hemoglobin and neurological outcomes following cardiac arrest. Relevant studies were identified by searching electronic databases including PubMed, Web of Science, Cochrane Library, and Embase from June 2012 through April 2023. Articles were rigorously reviewed for their study inclusion and exclusion criteria. Pooled effect date was determined using the standardized mean difference (SMD) and 95% confidence intervals (CI). The Newcastle-Ottawa Scale was used to evaluate study quality. Subgroup analyses were conducted to determine confounding factors affecting patient outcomes. Study heterogeneity, sensitivity, and publication bias were also determined.This meta-analysis included 11 studies involving 2519 patients. Our results suggest that high serum level of hemoglobin may improve neurological prognosis(SMD = 0.60, 95%CI = 0.49-0.71, I2 = 10.85). The findings of this study indicate that serum level of hemoglobin may be associated with better neurological prognosis, perhaps an appropriate increase in serum haemoglobin levels can improve the neurological prognosis of patients in cardiac arrest.
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Affiliation(s)
- Hongxiang Hou
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Li Pang
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Liang Zhao
- Rehabilitation Department, the First Hospital of Jilin University, Changchun, China
| | - Zuolong Liu
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China
| | - Ji-Hong Xing
- Department of Emergency, the First Hospital of Jilin University, Xinmin Street 1, Chaoyang District, Changchun, China.
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15
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Haschemi J, Müller CT, Haurand JM, Oehler D, Spieker M, Polzin A, Kelm M, Horn P. Lactate to Albumin Ratio for Predicting Clinical Outcomes after In-Hospital Cardiac Arrest. J Clin Med 2023; 12:4136. [PMID: 37373829 DOI: 10.3390/jcm12124136] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
In-hospital cardiac arrest (IHCA) is associated with high mortality and poor neurological outcomes. Our objective was to assess whether the lactate-to-albumin ratio (LAR) can predict the outcomes in patients after IHCA. We retrospectively screened 75,987 hospitalised patients at a university hospital between 2015 and 2019. The primary endpoint was survival at 30-days. Neurological outcomes were assessed at 30 days using the cerebral performance category scale. 244 patients with IHCA and return of spontaneous circulation (ROSC) were included in this study and divided into quartiles of LAR. Overall, there were no differences in key baseline characteristics or rates of pre-existing comorbidities among the LAR quartiles. Patients with higher LAR had poorer survival after IHCA compared to patients with lower LAR: Q1, 70.4% of the patients; Q2, 50.8% of the patients; Q3, 26.2% of the patients; Q4, 6.6% of the patients (p = 0.001). Across increasing quartiles, the probability of a favourable neurological outcome in patients with ROSC after IHCA decreased: Q1: 49.2% of the patients; Q2: 32.8% of the patients; Q3: 14.7% of the patients; Q4: 3.2% of the patients (p = 0.001). The AUCs for predicting 30-days survival using the LAR were higher as compared to using a single measurement of lactate or albumin. The prognostic performance of LAR was superior to that of a single measurement of lactate or albumin for predicting survival after IHCA.
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Affiliation(s)
- Jafer Haschemi
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Charlotte Theresia Müller
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Jean Marc Haurand
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Oehler
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Maximilian Spieker
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
- CARID, Cardiovascular Research Institute, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine University, 40225 Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
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16
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Wilson LD, Maiga AW, Lombardo S, Nordness MF, Haddad DN, Rakhit S, Smith LF, Rivera EL, Cook MR, Thompson JL, Raman R, Patel MB. Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study. Am J Surg 2023; 225:781-786. [PMID: 36372578 PMCID: PMC10750767 DOI: 10.1016/j.amjsurg.2022.10.003] [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: 08/11/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates. METHODS This single-center, six-year (2006-2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality. RESULTS Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death. CONCLUSIONS Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.
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Affiliation(s)
- Laura D Wilson
- Oxley College of Health Sciences, Communication Sciences and Disorders, The University of Tulsa, 800 S Tucker Dr, Tulsa, OK, 74104, USA
| | - Amelia W Maiga
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Sarah Lombardo
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Section of Acute Care Surgery, Division of General Surgery, Department of Surgery, University of Utah Health, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Diane N Haddad
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; The Trauma Center at Penn, 51 North 39th ST, MOB Suite 120, Philadelphia, PA, 19104, USA
| | - Shayan Rakhit
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Laney F Smith
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd, NW., Washington, D.C., 20057, USA
| | - Erika L Rivera
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Madison R Cook
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN, 37208, USA; Department of Surgery, Temple University Hospital, 3401 N. Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA, 19140, USA
| | - Jennifer L Thompson
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN, 37203, USA; Devoted Health, 221 Crescent St #202, Waltham, MA, 02453, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN, 37203, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Vanderbilt University Medical Center, Geriatric Research Education and Clinical Center, Surgical Services, Tennessee Valley Healthcare System, USA.
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17
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Denchev K, Gomez J, Chen P, Rosenblatt K. Traumatic Brain Injury: Intraoperative Management and Intensive Care Unit Multimodality Monitoring. Anesthesiol Clin 2023; 41:39-78. [PMID: 36872007 DOI: 10.1016/j.anclin.2022.11.003] [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: 03/07/2023]
Abstract
Traumatic brain injury is a devastating event associated with substantial morbidity. Pathophysiology involves the initial trauma, subsequent inflammatory response, and secondary insults, which worsen brain injury severity. Management entails cardiopulmonary stabilization and diagnostic imaging with targeted interventions, such as decompressive hemicraniectomy, intracranial monitors or drains, and pharmacological agents to reduce intracranial pressure. Anesthesia and intensive care requires control of multiple physiologic variables and evidence-based practices to reduce secondary brain injury. Advances in biomedical engineering have enhanced assessments of cerebral oxygenation, pressure, metabolism, blood flow, and autoregulation. Many centers employ multimodality neuromonitoring for targeted therapies with the hope to improve recovery.
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Affiliation(s)
- Krassimir Denchev
- Department of Anesthesiology, Wayne State University, 44555 Woodward Avenue, SJMO Medical Office Building, Suite 308, Pontiac, MI 48341, USA
| | - Jonathan Gomez
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA
| | - Pinxia Chen
- Department of Anesthesiology and Critical Care Medicine, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA; Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA.
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18
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Scurfield AK, Wilson MD, Gurkoff G, Martin R, Shahlaie K. Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage. Neurocrit Care 2023; 38:149-157. [PMID: 36050537 PMCID: PMC9957945 DOI: 10.1007/s12028-022-01587-z] [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: 03/18/2022] [Accepted: 08/08/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome. METHODS In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model. RESULTS Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model. CONCLUSIONS This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.
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Affiliation(s)
- Abby K Scurfield
- Frank H. Netter M.D. School of Medicine, Quinnipiac University, 830 Orange Street, New Haven, CT, 06511, USA
| | - Machelle D Wilson
- Division of Biostatistics, Department of Public Health Sciences, Davis Clinical and Translational Science Center, University of California, 2921 Stockton Blvd., Suite 1400, Sacramento, CA, 95817, USA
| | - Gene Gurkoff
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
| | - Ryan Martin
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA
- Department of Neurology, University of California, 4860 Y Street, Suite 3740,, Davis, Sacramento, CA, USA
| | - Kiarash Shahlaie
- Department of Neurological Surgery, University of California, 4860 Y Street, Suite 3740,, 95817, Davis, Sacramento, CA, USA.
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19
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Chen L, Xia S, Zuo Y, Lin Y, Qiu X, Chen Q, Feng T, Xia X, Shao Q, Wang S. Systemic immune inflammation index and peripheral blood carbon dioxide concentration at admission predict poor prognosis in patients with severe traumatic brain injury. Front Immunol 2023; 13:1034916. [PMID: 36700228 PMCID: PMC9868584 DOI: 10.3389/fimmu.2022.1034916] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023] Open
Abstract
Background Recent studies have shown that systemic inflammation responses and hyperventilation are associated with poor outcomes in patients with severe traumatic brain injury (TBI). The aim of this retrospective study was to investigate the relationships between the systemic immune inflammation index (SII = platelet × neutrophil/lymphocyte) and peripheral blood CO2 concentration at admission with the Glasgow Outcome Score (GOS) at 6 months after discharge in patients with severe TBI. Methods We retrospectively analyzed the clinical data for 1266 patients with severe TBI at three large medical centers from January 2016 to December 2021, and recorded the GOS 6 months after discharge. The receiver operating characteristic (ROC) curve was used to determine the best cutoff values for SII, CO2, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and lymphocyte to monocyte ratio (LMR), and chi-square tests were used to evaluate the relationships among SII, CO2 and the basic clinical characteristics of patients with TBI. Multivariate logistic regression analysis was used to determine the independent prognostic factors for GOS in patients with severe TBI. Finally, ROC curve, nomogram, calibration curve and decision curve analyses were used to evaluate the value of SII and coSII-CO2 in predicting the prognosis of patients with severe TBI. And we used the multifactor regression analysis method to build the CRASH model and the IMPACT model. The CRASH model included age, GCS score (GCS, Glasgow Coma Scale) and Pupillary reflex to light: one, both, none. The IMPACT model includes age, motor score and Pupillary reflex to light: one, both, none. Results The ROC curves indicated that the best cutoff values of SII, CO2, PLR, NLR and LMR were 2651.43×109, 22.15mmol/L, 190.98×109, 9.66×109 and 1.5×109, respectively. The GOS at 6 months after discharge of patients with high SII and low CO2 were significantly poorer than those with low SII and high CO2. Multivariate logistic regression analysis revealed that age, systolic blood pressure (SBP), pupil size, subarachnoid hemorrhage (SAH), SII, PLR, serum potassium concentration [K+], serum calcium concentration [Ca2+], international normalized ratio (INR), C-reactive protein (CRP) and co-systemic immune inflammation index combined with carbon dioxide (coSII-CO2) (P < 0.001) were independent prognostic factors for GOS in patients with severe TBI. In the training group, the C-index was 0.837 with SII and 0.860 with coSII-CO2. In the external validation group, the C-index was 0.907 with SII and 0.916 with coSII-CO2. Decision curve analysis confirmed a superior net clinical benefit with coSII-CO2 rather than SII in most cases. Furthermore, the calibration curve for the probability of GOS 6 months after discharge showed better agreement with the observed results when based on the coSII-CO2 rather than the SII nomogram. According to machine learning, coSII-CO2 ranked first in importance and was followed by pupil size, then SII. Conclusions SII and CO2 have better predictive performance than NLR, PLR and LMR. SII and CO2 can be used as new, accurate and objective clinical predictors, and coSII-CO2, based on combining SII with CO2, can be used to improve the accuracy of GOS prediction in patients with TBI 6 months after discharge.
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Affiliation(s)
- Li Chen
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China
| | - Shaohuai Xia
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China
| | - Yi Zuo
- Department of Geriatrics, Affiliated Huai’an No.2 People’s Hospital of Xuzhou Medical University, Huai’an, Jiangsu, China
| | - Yinghong Lin
- Department of Neurosurgery, 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Xianshen Qiu
- Department of Neurosurgery, Ganzhou People's Hospital, No.16 Meiguan Avenue, Zhanggong District, Ganzhou, Jiangxi, China
| | - Qizuan Chen
- Department of Neurosurgery, 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Tianshun Feng
- Department of Neurosurgery, 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Xuewei Xia
- Department of Neurosurgery, Affiliated Hospital of Guilin Medical University, Guilin, Guangxi, China,*Correspondence: Xuewei Xia, ; Qixiang Shao, ; Shousen Wang,
| | - Qixiang Shao
- Institute of Medical Genetics and Reproductive Immunity, School of Medical Science and Laboratory Medicine, Jiangsu College of Nursing, No.2 the Yellow River West Road Huai'an, Jiangsu, China,*Correspondence: Xuewei Xia, ; Qixiang Shao, ; Shousen Wang,
| | - Shousen Wang
- Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China,Department of Neurosurgery, 900th Hospital, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China,*Correspondence: Xuewei Xia, ; Qixiang Shao, ; Shousen Wang,
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Bakhsh A, Anwar S, Manivannan S, Gillepsie C, Wilson M, Khan M. Haemoglobin Threshold for Red Blood Cell Transfusion in Traumatic Brain Injury: a Systematic Review and Meta-Analysis. CURRENT ANESTHESIOLOGY REPORTS 2023. [DOI: 10.1007/s40140-022-00544-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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21
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Wallen TE, Baucom MR, England LG, Schuster RM, Pritts TA, Goodman MD. MULTIMODAL TREATMENT APPROACHES TO COMBINED TRAUMATIC BRAIN INJURY AND HEMORRHAGIC SHOCK ALTER POSTINJURY INFLAMMATORY RESPONSE. Shock 2022; 58:565-572. [PMID: 36548646 DOI: 10.1097/shk.0000000000002014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT Introduction: The optimal management strategies for patients with polytraumatic injuries that include traumatic brain injury (TBI) are not well defined. Specific interventions including tranexamic acid (TXA), propranolol, and hypertonic saline (HTS) have each demonstrated benefits in patient mortality after TBI, but have not been applied to TBI patients with concomitant hemorrhage. The goals of our study were to determine the inflammatory effects of resuscitation strategy using HTS or shed whole blood (WB) and evaluate the cerebral and systemic inflammatory effects of adjunct treatment with TXA and propranolol after combined TBI + hemorrhagic shock. Methods: Mice underwent TBI via weight drop and were subsequently randomized into six experimental groups: three with HTS resuscitation and three with WB resuscitation. Mice were then subjected to controlled hemorrhagic shock for 1 h to a goal MAP of 25 mmHg. Mice were then treated with an i.p. dose of 4 mg/kg propranolol, 100 mg/kg TXA, or normal saline (NS) as a control. Mice were killed at 1, 6, or 24 h for serum and cerebral biomarker evaluation by multiplex ELISA and serum neuron-specific enolase, a biomarker of cerebral cellular injury. Results: Mice resuscitated with HTS had elevated serum proinflammatory cytokines compared with WB resuscitated groups at 6 and 24 h after injury, with no significant difference in cerebral cytokine levels. Within the TBI/shock + HTS groups, the addition of propranolol or TXA did not significantly alter serum cytokine concentration, but cerebral IL-2, IL-12, and macrophage inflammatory protein-1α (MIP-1α) decreased after propranolol administration. In the TBI/shock + WB cohorts, the addition of both propranolol and TXA increased systemic proinflammatory cytokine levels at 6 and 24 h after injury as demonstrated by serum IL-2, IL-12, MIP-1α, and IL-1β compared with NS control. By contrast, TBI/shock + WB mice demonstrated a significant reduction in cerebral IL-2, IL-12, and MIP-1α in propranolol treated mice 6 h after injury compared with NS group. While serum neuron-specific enolase was significantly increased 1 and 24 h after injury in TBI/shock + HTS + TXA cohorts compared with NS control, it was significantly reduced in the TBI/shock + WB + propranolol mice compared with NS control 24 h after injury. Conclusions: Whole blood resuscitation can reduce the acute postinjury neuroinflammatory response after combined TBI/shock compared with HTS. The addition of either propranolol or TXA may modulate the postinjury systemic and cerebral inflammatory response with more improvements noted after propranolol administration. Multimodal treatment with resuscitation and pharmacologic therapy after TBI and hemorrhagic shock may mitigate the inflammatory response to these injuries to improve recovery.
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Affiliation(s)
- Taylor E Wallen
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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22
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Vanhala H, Junttila E, Kataja A, Huhtala H, Luostarinen T, Luoto T. Incidence and Associated Factors of Anemia in Patients with Acute Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:629-637. [PMID: 35915348 PMCID: PMC9671999 DOI: 10.1007/s12028-022-01561-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/17/2022] [Indexed: 12/05/2022]
Abstract
Background Anemia might contribute to the development of secondary injury in patients with acute traumatic brain injury (TBI). Potential determinants of anemia are still poorly acknowledged, and reported incidence of declined hemoglobin concentration varies widely between different studies. The aim of this study was to investigate the incidence of severe anemia among patients with moderate to severe TBI and to evaluate patient- and trauma-related factors that might be associated with the development of anemia. Methods This retrospective cohort study involved all adult patients admitted to Tampere University Hospital’s emergency department for moderate to severe TBI (August 2010 to July 2012). Detailed information on patient demographics and trauma characteristics were obtained, including data on posttraumatic care, data on neurosurgical procedures, and all measured in-hospital hemoglobin values. Severe anemia was defined as a hemoglobin level less than 100 g/L. Both univariate and multivariable analyses were performed, and hemoglobin trajectories were created. Results The study included 145 patients with moderate to severe TBI (male 83.4%, mean age 55.0 years). Severe anemia, with a hemoglobin level less than 100 g/L, was detected in 66 patients (45.5%) and developed during the first 48 h after the trauma. In the univariate analysis, anemia was more common among women (odds ratio [OR] 2.84; 95% confidence interval [CI] 1.13–7.15), patients with antithrombotic medication prior to trauma (OR 3.33; 95% CI 1.34–8.27), patients with cardiovascular comorbidities (OR 3.12; 95% CI 1.56–6.25), patients with diabetes (OR 4.56; 95% CI 1.69–12.32), patients with extracranial injuries (OR 3.14; 95% CI 1.69–12.32), and patients with midline shift on primary head computed tomography (OR 2.03; 95% CI 1.03–4.01). In the multivariable analysis, midline shift and extracranial traumas were associated with the development of severe anemia (OR 2.26 [95% CI 1.05–4.48] and OR 4.71 [95% CI 1.74–12.73], respectively). Conclusions Severe anemia is common after acute moderate to severe TBI, developing during the first 48 h after the trauma. Possible anemia-associated factors include extracranial traumas and midline shift on initial head computed tomography.
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Affiliation(s)
- Heidi Vanhala
- Department of Anesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland.
| | - Eija Junttila
- Department of Anesthesia and Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Anneli Kataja
- Medical Imaging Center, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Biostatistics Group, Tampere University, Tampere, Finland
| | - Teemu Luostarinen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Teemu Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
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23
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Factors Associated With Brain Tissue Oxygenation Changes After RBC Transfusion in Acute Brain Injury Patients. Crit Care Med 2022; 50:e539-e547. [PMID: 35132018 DOI: 10.1097/ccm.0000000000005460] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Anemia is common after acute brain injury and can be associated with brain tissue hypoxia. RBC transfusion (RBCT) can improve brain oxygenation; however, predictors of such improvement remain unknown. We aimed to identify the factors associated with PbtO2 increase (greater than 20% from baseline value) after RBCT, using a generalized mixed model. DESIGN This is a multicentric retrospective cohort study (2012-2020). SETTING This study was conducted in three European ICUs of University Hospitals located in Belgium, Switzerland, and Austria. PATIENTS All patients with acute brain injury who were monitored with brain tissue oxygenation (PbtO2) catheters and received at least one RBCT. INTERVENTION Patients received at least one RBCT. PbtO2 was recorded before, 1 hour, and 2 hours after RBCT. MEASUREMENTS AND MAIN RESULTS We included 69 patients receiving a total of 109 RBCTs after a median of 9 days (5-13 d) after injury. Baseline hemoglobin (Hb) and PbtO2 were 7.9 g/dL [7.3-8.7 g/dL] and 21 mm Hg (16-26 mm Hg), respectively; 2 hours after RBCT, the median absolute Hb and PbtO2 increases from baseline were 1.2 g/dL [0.8-1.8 g/dL] (p = 0.001) and 3 mm Hg (0-6 mm Hg) (p = 0.001). A 20% increase in PbtO2 after RBCT was observed in 45 transfusions (41%). High heart rate (HR) and low PbtO2 at baseline were independently associated with a 20% increase in PbtO2 after RBCT. Baseline PbtO2 had an area under receiver operator characteristic of 0.73 (95% CI, 0.64-0.83) to predict PbtO2 increase; a PbtO2 of 20 mm Hg had a sensitivity of 58% and a specificity of 73% to predict PbtO2 increase after RBCT. CONCLUSIONS Lower PbtO2 values and high HR at baseline could predict a significant increase in brain oxygenation after RBCT.
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Montgomery EY, Barrie U, Kenfack YJ, Edukugho D, Caruso JP, Rail B, Hicks WH, Oduguwa E, Pernik MN, Tao J, Mofor P, Adeyemo E, Ahmadieh TYE, Tamimi MA, Bagley CA, Bedros N, Aoun SG. Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence. Neurotrauma Rep 2022; 3:554-568. [PMID: 36636743 PMCID: PMC9811955 DOI: 10.1089/neur.2022.0056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.
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Affiliation(s)
- Eric Y. Montgomery
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Address correspondence to: Eric Y. Montgomery, BA, Department of Neurosurgery, The University of Texas Southwestern, 5151 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yves J. Kenfack
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Derrek Edukugho
- Department of Neurological Surgery, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, USA
| | - James P. Caruso
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin Rail
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William H. Hicks
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuella Oduguwa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mark N. Pernik
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jonathan Tao
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paula Mofor
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emmanuel Adeyemo
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tarek Y. El Ahmadieh
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mazin Al Tamimi
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carlos A. Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bedros
- Department of Surgery, Baylor University Medical Center, Dallas, Texas, USA
| | - Salah G. Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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25
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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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Digital signatures for early traumatic brain injury outcome prediction in the intensive care unit. Sci Rep 2021; 11:19989. [PMID: 34620915 PMCID: PMC8497604 DOI: 10.1038/s41598-021-99397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/23/2021] [Indexed: 11/08/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading neurological cause of death and disability across the world. Early characterization of TBI severity could provide a window for therapeutic intervention and contribute to improved outcome. We hypothesized that granular electronic health record data available in the first 24 h following admission to the intensive care unit (ICU) can be used to differentiate outcomes at discharge. Working from two ICU datasets we focused on patients with a primary admission diagnosis of TBI whose length of stay in ICU was ≥ 24 h (N = 1689 and 127). Features derived from clinical, laboratory, medication, and physiological time series data in the first 24 h after ICU admission were used to train elastic-net regularized Generalized Linear Models for the prediction of mortality and neurological function at ICU discharge. Model discrimination, determined by area under the receiver operating characteristic curve (AUC) analysis, was 0.903 and 0.874 for mortality and neurological function, respectively. Model performance was successfully validated in an external dataset (AUC 0.958 and 0.878 for mortality and neurological function, respectively). These results demonstrate that computational analysis of data routinely collected in the first 24 h after admission accurately and reliably predict discharge outcomes in ICU stratum TBI patients.
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Cerebrovascular pressure reactivity and intracranial pressure are associated with neurologic outcome after hypoxic-ischemic brain injury. Resuscitation 2021; 164:114-121. [PMID: 33930501 DOI: 10.1016/j.resuscitation.2021.04.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/09/2021] [Accepted: 04/20/2021] [Indexed: 11/21/2022]
Abstract
AIM We evaluated the association of physiological parameters measured by intracranial multimodality neuromonitoring with neurologic outcome in a consecutive series of patients with hypoxic-ischemic brain injury (HIBI). METHODS We retrospectively identified all patients with HIBI who underwent combined invasive intracranial pressure (ICP) and brain tissue oxygen (PbtO2) monitoring over a 3 year period. Cerebrovascular pressure reactivity index (PRx) was calculated continuously as a surrogate of cerebral autoregulation. Favorable outcome was defined as recovery of consciousness (Glasgow Coma Scale motor score = 6). Differences in mean ICP, PRx and PbtO2 for the entire monitoring period across outcomes were measured. Logistic regression and area under receiver operating characteristic (AUROC) curve were used to assess the association of each monitoring parameter with neurologic outcome. RESULTS We analyzed data from 36 patients. Most (89%) had an antecedent sudden cardiac arrest. Favorable outcome occurred in 8 (22%) patients. ICP and PRx were higher in patients with unfavorable outcome (ICP: 26 ± 4.1 mmHg vs 7.5 ± 2 mmHg, p = 0.0002; PRx: 0.51 ± 0.05 vs 0.11 ± 0.05, p < 0.0001). There was no significant difference in PbtO2 between groups (unfavorable: 20 ± 2.4 mmHg vs favorable: 25 ± 1.5 mmHg, p = 0.12). Both ICP (AUROC 0.84, 95%CI 0.72-0.98, p = 0.003) and PRx (AUROC 0.94, 95%CI 0.85-1, p = 0.0002) discriminated between favorable and unfavorable outcome, in contrast to PbtO2, (AUROC 0.59, 95%CI 0.39-0.78, p = 0.52). ICP > 15 mmHg, PRx > 0.2, and PbtO2 < 18 mmHg had sensitivity/specificity of 68%/100%, 89%/88%, and 40%/100% respectively for discriminating outcomes. CONCLUSION Cerebrovascular pressure reactivity and intracranial pressure appear to be associated with neurologic outcome in patients with HIBI.
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Svedung Wettervik TM, Lewén A, Enblad P. Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care-Indicative Observations and Future Perspectives. Front Neurol 2021; 12:638132. [PMID: 33716941 PMCID: PMC7943830 DOI: 10.3389/fneur.2021.638132] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/20/2021] [Indexed: 01/01/2023] Open
Abstract
Neurointensive care (NIC) has contributed to great improvements in clinical outcomes for patients with severe traumatic brain injury (TBI) by preventing, detecting, and treating secondary insults and thereby reducing secondary brain injury. Traditional NIC management has mainly focused on generally applicable escalated treatment protocols to avoid high intracranial pressure (ICP) and to keep the cerebral perfusion pressure (CPP) at sufficiently high levels. However, TBI is a very heterogeneous disease regarding the type of injury, age, comorbidity, secondary injury mechanisms, etc. In recent years, the introduction of multimodality monitoring, including, e.g., pressure autoregulation, brain tissue oxygenation, and cerebral energy metabolism, in addition to ICP and CPP, has increased the understanding of the complex pathophysiology and the physiological effects of treatments in this condition. In this article, we will present some potential future approaches for more individualized patient management and fine-tuning of NIC, taking advantage of multimodal monitoring to further improve outcome after severe TBI.
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Affiliation(s)
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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A multi-domain prognostic model of disorder of consciousness using resting-state fMRI and laboratory parameters. Brain Imaging Behav 2020; 15:1966-1976. [PMID: 33040258 DOI: 10.1007/s11682-020-00390-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Although laboratory parameters have long been recognized as indicators of outcome of traumatic brain injury (TBI), it remains a challenge to predict the recovery of disorder of consciousness (DOC) in severe brain injury including TBI. Recent advances have shown an association between alterations in brain connectivity and recovery from DOC. In the present study, we developed a prognostic model of DOC recovery via a combination of laboratory parameters and resting-state functional magnetic resonance imaging (fMRI). METHODS Fifty-one patients with DOC (age = 52.3 ± 15.2 y, male/female = 31/20) were recruited from Hangzhou Hospital of Zhejiang CAPR and were sub-grouped into conscious (n = 34) and unconscious (n = 17) groups based upon their Glasgow Outcome Scale-Extended (GOS-E) scores at 12-month follow-ups after injury. Resting-state functional connectivity, network nodal measures (centrality), and laboratory parameters were obtained from each patient and served as features for support vector machine (SVM) classifications. RESULTS We found that functional connectivity was the most accurate single-domain model (ACC: 70.1% ± 4.5%, P = 0.038, 1000 permutations), followed by degree centrality, betweenness centrality, and laboratory parameters. The stacked multi-domain prognostic model (ACC: 73.4% ± 3.1%, P = 0.005, 1000 permutations) combining all single-domain models yielded a significantly higher accuracy compared to that of the best-performing single-domain model (P = 0.002). CONCLUSION Our results suggest that laboratory parameters only contribute to the outcome prediction of DOC patients, whereas combining information from neuroimaging and clinical parameters may represent a strategy to achieve a more accurate prognostic model, which may further provide better guidance for clinical management of DOC patients.
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Roh DJ, Carvalho Poyraz F, Magid-Bernstein J, Elkind MSV, Agarwal S, Park S, Claassen J, Connolly ES, Hod E, Murthy SB. Red Blood Cell Transfusions and Outcomes After Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105317. [PMID: 32992186 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105317] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Low red blood cell (RBC) levels are associated with worse intracerebral hemorrhage (ICH) outcomes. However, relationships of RBC transfusions on ICH outcomes are unclear given the overlap of RBC transfusion, comorbidities, and disease severity. We investigated RBC transfusion relationships on ICH outcomes while accounting for comorbidities and disease severity. METHODS ICH hospitalizations between 2002 and 2011 and RBC transfusion exposure were identified from the Nationwide Inpatient Sample using ICD-9-CM codes. Logistic regression was used to study the relationship between RBC transfusion on outcomes after adjusting for demographics, baseline comorbidities, and markers of disease severity. Additional sensitivity analyses stratified by comorbidity burden and disease severity were performed. RESULTS Of 597,046 ICH hospitalizations, RBC transfusions were administered in 22,904 (4%). RBC transfusion was associated with higher odds of in-hospital mortality (adjusted OR: 1.22 [95%CI: 1.10-1.35]). In sensitivity analyses, RBC transfusions resulted in poor outcomes regardless of the comorbidity burden, but attenuation in this relationship was notable with lower comorbidities (adjusted OR 1.43 [95%CI: 1.34-1.51] vs 1.18 [95%CI: 1.10-1.29]). There were no associations of RBC transfusions with poor outcomes in hospitalizations without mechanical ventilation (adjusted OR 0.88 [95%CI: 0.83-1.13]) and in cases requiring ventriculostomy drains (adjusted OR 1.05 [95%CI: 0.97-1.10]). CONCLUSIONS In a large, nationally representative sample, RBC transfusion was associated with poor ICH outcomes. However, there were variations in this relationship based on comorbidities and disease severity. Additional prospective studies are required to assess direct risks and benefits from RBC transfusions in ICH.
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Affiliation(s)
- David J Roh
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Fernanda Carvalho Poyraz
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Jessica Magid-Bernstein
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Mitchell S V Elkind
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States; Mailman School of Public Health, Columbia University, New York, NY, United States.
| | - Sachin Agarwal
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Soojin Park
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - Jan Claassen
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, 177 Fort Washington Ave, New York, NY, United States.
| | - E Sander Connolly
- Vagelos College of Physicians and Surgeons, Department of Neurosurgery, Columbia University, New York, NY, United States.
| | - Eldad Hod
- Vagelos College of Physicians and Surgeons, Department of Pathology and Cell Biology, Columbia University, New York, NY, United States.
| | - Santosh B Murthy
- Clinical and Translational Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College, New York, NY, United States.
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When to transfuse your acute care patient? A narrative review of the risk of anemia and red blood cell transfusion based on clinical trial outcomes. Can J Anaesth 2020; 67:1576-1594. [DOI: 10.1007/s12630-020-01763-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 12/14/2022] Open
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Zama Cavicchi F, Iesu E, Franchi F, Nobile L, Annoni F, Vincent JL, Scolletta S, Creteur J, Taccone FS. Low hemoglobin and venous saturation levels are associated with poor neurological outcomes after cardiac arrest. Resuscitation 2020; 153:202-208. [PMID: 32592732 DOI: 10.1016/j.resuscitation.2020.06.020] [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: 12/31/2019] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hemoglobin (Hb) is a main determinant of tissue oxygen delivery and anemia could be particularly harmful in post-anoxic brain injury. The aim of this study was to evaluate the association of Hb and venous Hb oxygen saturation (SvO2/ScvO2) with long-term neurological outcome in patients admitted after cardiac arrest (CA). METHODS Analysis of adult CA patients admitted to the Department of Intensive Care of the Erasme University Hospital (Brussels, Belgium) over 9 years. We retrieved all data concerning CA characteristics as well as Hb during the first 48 h since injury as well as the need for red blood cells transfusions (RBCT). Minimum Hb and Hb oxygen saturation values were recorded. Neurological outcome was evaluated 3 months after CA. Unfavorable neurological outcome (UO) was defined as a Cerebral Performance Categories (CPC) score of 3-5. RESULTS We treated 414 patients patients with CA, including 231 (56%) out-of-hospital cardiac arrest (OHCA) and 158 (38%) with an initial shockable rhythm. Median Hb concentration on admission was 12.0 [9.9-13.7] g/dL and the lowest Hb concentration was 10.0 [8.1-11.0] g/dL; 127 patients (31%) received at least one RBCT. Hb oxygen saturation on admission was 67 [59-74]%, while the lowest value was 60 [53-68]%. Low Hb and Hb oxygen saturation values were independently associated with UO; the optimal cut-off to predict UO was <9.9 g/dL and <60%, respectively. CONCLUSIONS Low hemoglobin values and low values of oxygen venous saturation are significantly associated with unfavorable neurological outcome in adult patients resuscitated from cardiac arrest.
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Affiliation(s)
- Federica Zama Cavicchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Enrica Iesu
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Federico Franchi
- Department of Emergency Medicine, Surgery and Neurosciences, Intensive Care Unit, Università di Siena, Siena, Italy
| | - Leda Nobile
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Sabino Scolletta
- Department of Emergency Medicine, Surgery and Neurosciences, Intensive Care Unit, Università di Siena, Siena, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Precision Medicine in Acute Brain Injury: A Narrative Review. J Neurosurg Anesthesiol 2020; 34:e14-e23. [PMID: 32590476 DOI: 10.1097/ana.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/24/2020] [Indexed: 11/26/2022]
Abstract
Over the past few years, the concept of personalized medicine has percolated into the management of different neurological conditions. Improving outcomes after acute brain injury (ABI) continues to be a major challenge. Unrecognized individual multiomic variations in addition to multiple interacting processes may explain why we fail to observe comprehensive improvements in ABI outcomes even when applied treatments appear to be beneficial logically. The provision of clinical care based on a multiomic approach may revolutionize the management of traumatic brain injury, delayed cerebral ischemia after subarachnoid hemorrhage, acute ischemic stroke, and several other neurological diseases. The challenge is to incorporate all the information obtained from genomic studies, other omic data, and individual variability into a practical tool that can be used to assist clinical decision-making. The effective execution of such strategies, which is still far away, requires the development of protocols on the basis of these complex interactions and strict adherence to management protocols. In this review, we will discuss various omics and physiological targets to guide individualized patient management after ABI.
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Bagheri Z, Labbani-Motlagh Z, Mirjalili M, Karimzadeh I, Khalili H. Types and outcomes of cytopenia in critically ill patients. J Comp Eff Res 2020; 9:627-637. [PMID: 32495631 DOI: 10.2217/cer-2020-0044] [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: 11/21/2022] Open
Abstract
Cytopenia is common complication in critically ill patients. Aim: Incidence and pattern of different types of cytopenia as well as its impact on mortality and length of stay in critically ill patients were evaluated. Methods: Critically ill patients with any kind of cytopenia for more than 2 days were evaluated. Results: Anemia was the most common type of cytopenia in the patients (99.14%), followed by lymphocytopenia (32.17%), thrombocytopenia (27.82%), and leukopenia (19.13%). Mortality rate was significantly higher in patients with anemia (p < 0.0001), thrombocytopenia (p < 0.0001), leukopenia (p < 0.0001), neutropenia (p = 0.004), lymphopenia (p = 0.002) and pancytopenia (p < 0.0001). Higher duration of anemia, lymphopenia and thrombocytopenia were associated with longer intensive care unit stay (p < 0.0001, p < 0.0001 and p < 0.001, respectively). Conclusion: Among all assessed variables, incidence of thrombocytopenia could independently predict the mortality.
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Affiliation(s)
- Zahra Bagheri
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohreh Labbani-Motlagh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Luo HC, Fu YQ, You CY, Liu CJ, Xu F. Comparison of admission serum albumin and hemoglobin as predictors of outcome in children with moderate to severe traumatic brain injury: A retrospective study. Medicine (Baltimore) 2019; 98:e17806. [PMID: 31689863 PMCID: PMC6946495 DOI: 10.1097/md.0000000000017806] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hypoalbuminemia and anemia are frequent among in patients with traumatic brain injury (TBI). We assess whether serum albumin and hemoglobin at admission can predict outcome in children with moderate to severe TBI.This retrospective study was conducted in a tertiary pediatric hospital between May 2012 and Jun 2018 included children with an admission Glasgow Coma Scale of ≤13.A total of 213 patients were included of whom 45 died in hospital. Multivariate logistic regression showed that hypoalbuminemia (serum albumin <30 g/L) was independently associated with mortality (adjusted odds ratio [OR] = 3.059; 95% confidence interval [CI]: 1.118-8.371; P = .030) in children with moderate to severe TBI, while anemia (hemoglobin <90 g/L) was not independently associated with mortality (adjusted OR = 1.742; 95% CI: 0.617-4.916; P = .295). Serum albumin was significantly superior to hemoglobin (area under the curve [AUC] 0.738 vs AUC 0.689, P < .05) under receiver operating characteristic curve analysis. Hypoalbuminemia was also associated with reduced 14-day ventilation-free days, 14-day intensive care unit (ICU)-free days, and 28-day hospital-free days.Serum albumin at admission was superior to hemoglobin in predicting the mortality in children with moderate to severe TBI and also associated with reduced ventilator-free, ICU-free, and hospital-free days.
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Affiliation(s)
- Hong-chun Luo
- Department of Infectious Diseases, The First Affiliated Hospital
| | - Yue-qiang Fu
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Cheng-yan You
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Cheng-jun Liu
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders
- National Clinical Research Center for Child Health and Disorders (Chongqing)
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Stolla M, Zhang F, Meyer MR, Zhang J, Dong JF. Current state of transfusion in traumatic brain injury and associated coagulopathy. Transfusion 2019; 59:1522-1528. [PMID: 30980753 DOI: 10.1111/trf.15169] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/10/2018] [Accepted: 11/17/2018] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury (TBI)-induced coagulopathy has long been recognized as a significant risk for poor outcomes in patients with TBI, but its pathogenesis remains poorly understood. As a result, current treatment options for the condition are limited and ineffective. The lack of information is most significant for the impact of blood transfusions on patients with isolated TBI and in the absence of confounding influences from trauma to the body and limbs and the resultant hemorrhagic shock. Here we discuss recent progress in understanding the pathogenesis of TBI-induced coagulopathy and the current state of blood transfusions for patients with TBI and associated coagulopathy.
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Affiliation(s)
- Moritz Stolla
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Meyer
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China.,Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, Washington.,Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, Washington
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Abdelmalik PA, Draghic N, Ling GSF. Management of moderate and severe traumatic brain injury. Transfusion 2019; 59:1529-1538. [PMID: 30980755 DOI: 10.1111/trf.15171] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 12/28/2022]
Abstract
Traumatic brain injury (TBI) is a common disorder with high morbidity and mortality, accounting for one in every three deaths due to injury. Older adults are especially vulnerable. They have the highest rates of TBI-related hospitalization and death. There are about 2.5 to 6.5 million US citizens living with TBI-related disabilities. The cost of care is very high. Aside from prevention, little can be done for the initial primary injury of neurotrauma. The tissue damage incurred directly from the inciting event, for example, a blow to the head or bullet penetration, is largely complete by the time medical care can be instituted. However, this event will give rise to secondary injury, which consists of a cascade of changes on a cellular and molecular level, including cellular swelling, loss of membrane gradients, influx of immune and inflammatory mediators, excitotoxic transmitter release, and changes in calcium dynamics. Clinicians can intercede with interventions to improve outcome in the mitigating secondary injury. The fundamental concepts in critical care management of moderate and severe TBI focus on alleviating intracranial pressure and avoiding hypotension and hypoxia. In addition to these important considerations, mechanical ventilation, appropriate transfusion of blood products, management of paroxysmal sympathetic hyperactivity, using nutrition as a therapy, and, of course, venous thromboembolism and seizure prevention are all essential in the management of moderate to severe TBI patients. These concepts will be reviewed using the recent 2016 Brain Trauma Foundation Guidelines to discuss best practices and identify future research priorities.
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Affiliation(s)
| | - Nicole Draghic
- Department of Clinical Neurosciences, Inova Fairfax Hospital, Falls Church, Virginia
| | - Geoffrey S F Ling
- Department of Clinical Neurosciences, Inova Fairfax Hospital, Falls Church, Virginia.,Neurosciences Critical Care, Departments of Neurology, Neurosurgery and Anesthesiology-Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Nag DS, Sahu S, Swain A, Kant S. Intracranial pressure monitoring: Gold standard and recent innovations. World J Clin Cases 2019; 7:1535-1553. [PMID: 31367614 PMCID: PMC6658373 DOI: 10.12998/wjcc.v7.i13.1535] [Citation(s) in RCA: 126] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Shashi Kant
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
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Roh DJ, Albers DJ, Magid-Bernstein J, Doyle K, Hod E, Eisenberger A, Murthy S, Witsch J, Park S, Agarwal S, Connolly ES, Elkind MSV, Claassen J. Low hemoglobin and hematoma expansion after intracerebral hemorrhage. Neurology 2019; 93:e372-e380. [PMID: 31209179 DOI: 10.1212/wnl.0000000000007820] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/08/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Studies have independently shown associations of lower hemoglobin levels with larger admission intracerebral hemorrhage (ICH) volumes and worse outcomes. We investigated whether lower admission hemoglobin levels are associated with more hematoma expansion (HE) after ICH and whether this mediates lower hemoglobin levels' association with worse outcomes. METHODS Consecutive patients enrolled between 2009 and 2016 to a single-center prospective ICH cohort study with admission hemoglobin and neuroimaging data to calculate HE (>33% or >6 mL) were evaluated. The association of admission hemoglobin levels with HE and poor clinical outcomes using modified Rankin Scale (mRS 4-6) were assessed using separate multivariable logistic regression models. Mediation analysis investigated causal associations among hemoglobin, HE, and outcome. RESULTS Of 256 patients with ICH meeting inclusion criteria, 63 (25%) had HE. Lower hemoglobin levels were associated with increased odds of HE (odds ratio [OR] 0.80 per 1.0 g/dL change of hemoglobin; 95% confidence interval [CI] 0.67-0.97) after adjusting for previously identified covariates of HE (admission hematoma volume, antithrombotic medication use, symptom onset to admission CT time) and hemoglobin (age, sex). Lower hemoglobin was also associated with worse 3-month outcomes (OR 0.76 per 1.0 g/dL change of hemoglobin; 95% CI 0.62-0.94) after adjusting for ICH score. Mediation analysis revealed that associations of lower hemoglobin with poor outcomes were mediated by HE (p = 0.01). CONCLUSIONS Further work is required to replicate the associations of lower admission hemoglobin levels with increased odds of HE mediating worse outcomes after ICH. If confirmed, an investigation into whether hemoglobin levels can be a modifiable target of treatment to improve ICH outcomes may be warranted.
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Affiliation(s)
- David J Roh
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT.
| | - David J Albers
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Jessica Magid-Bernstein
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Kevin Doyle
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Eldad Hod
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Andrew Eisenberger
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Santosh Murthy
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Jens Witsch
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Soojin Park
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Sachin Agarwal
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - E Sander Connolly
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Mitchell S V Elkind
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
| | - Jan Claassen
- From Vagelos College of Physicians and Surgeons (D.J.R., D.J.A., J.M.-B., K.D., E.H., A.E., S.P., S.A., E.S.C., M.S.V.E., J.C.), Columbia University; Weill Cornell Medical Center (S.M.), New York, NY; and Yale School of Medicine (J.W.), New Haven, CT
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Is hemoglobin good for cerebral oxygenation and clinical outcome in acute brain injury? Curr Opin Crit Care 2019; 24:91-96. [PMID: 29401175 DOI: 10.1097/mcc.0000000000000485] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight the role of hemoglobin in cerebral physiology and pathophysiology. We review the existing as well as recent evidence detailing the effects of red blood cell transfusion on cerebral oxygenation and clinical outcome. RECENT FINDINGS Hemoglobin is a key component in oxygen delivery, and thus cerebral oxygenation. Higher hemoglobin levels and red blood cell transfusion are associated with higher cerebral oxygen delivery and decreased cerebral ischemic burden. Recent studies suggest that this may be associated with improved clinical outcomes. However, these results are limited to only a few, small studies and the results have not been consistent. Further studies are required. SUMMARY Hemoglobin is important for cerebral oxygenation and strategies to minimize anemia should be undertaken. Although higher hemoglobin levels are associated with less cerebral ischemia and better clinical outcome, whether this remains true whenever red blood cell transfusion is used to achieve this result remains unclear.
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Andrews PJ, Sinclair HL, Rodríguez A, Harris B, Rhodes J, Watson H, Murray G. Therapeutic hypothermia to reduce intracranial pressure after traumatic brain injury: the Eurotherm3235 RCT. Health Technol Assess 2019; 22:1-134. [PMID: 30168413 DOI: 10.3310/hta22450] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of disability and death in young adults worldwide. It results in around 1 million hospital admissions annually in the European Union (EU), causes a majority of the 50,000 deaths from road traffic accidents and leaves a further ≈10,000 people severely disabled. OBJECTIVE The Eurotherm3235 Trial was a pragmatic trial examining the effectiveness of hypothermia (32-35 °C) to reduce raised intracranial pressure (ICP) following severe TBI and reduce morbidity and mortality 6 months after TBI. DESIGN An international, multicentre, randomised controlled trial. SETTING Specialist neurological critical care units. PARTICIPANTS We included adult participants following TBI. Eligible patients had ICP monitoring in place with an ICP of > 20 mmHg despite first-line treatments. Participants were randomised to receive standard care with the addition of hypothermia (32-35 °C) or standard care alone. Online randomisation and the use of an electronic case report form (CRF) ensured concealment of random treatment allocation. It was not possible to blind local investigators to allocation as it was obvious which participants were receiving hypothermia. We collected information on how well the participant had recovered 6 months after injury. This information was provided either by the participant themself (if they were able) and/or a person close to them by completing the Glasgow Outcome Scale - Extended (GOSE) questionnaire. Telephone follow-up was carried out by a blinded independent clinician. INTERVENTIONS The primary intervention to reduce ICP in the hypothermia group after randomisation was induction of hypothermia. Core temperature was initially reduced to 35 °C and decreased incrementally to a lower limit of 32 °C if necessary to maintain ICP at < 20 mmHg. Rewarming began after 48 hours if ICP remained controlled. Participants in the standard-care group received usual care at that centre, but without hypothermia. MAIN OUTCOME MEASURES The primary outcome measure was the GOSE [range 1 (dead) to 8 (upper good recovery)] at 6 months after the injury as assessed by an independent collaborator, blind to the intervention. A priori subgroup analysis tested the relationship between minimisation factors including being aged < 45 years, having a post-resuscitation Glasgow Coma Scale (GCS) motor score of < 2 on admission, having a time from injury of < 12 hours and patient outcome. RESULTS We enrolled 387 patients from 47 centres in 18 countries. The trial was closed to recruitment following concerns raised by the Data and Safety Monitoring Committee in October 2014. On an intention-to-treat basis, 195 participants were randomised to hypothermia treatment and 192 to standard care. Regarding participant outcome, there was a higher mortality rate and poorer functional recovery at 6 months in the hypothermia group. The adjusted common odds ratio (OR) for the primary statistical analysis of the GOSE was 1.54 [95% confidence interval (CI) 1.03 to 2.31]; when the GOSE was dichotomised the OR was 1.74 (95% CI 1.09 to 2.77). Both results favoured standard care alone. In this pragmatic study, we did not collect data on adverse events. Data on serious adverse events (SAEs) were collected but were subject to reporting bias, with most SAEs being reported in the hypothermia group. CONCLUSIONS In participants following TBI and with an ICP of > 20 mmHg, titrated therapeutic hypothermia successfully reduced ICP but led to a higher mortality rate and worse functional outcome. LIMITATIONS Inability to blind treatment allocation as it was obvious which participants were randomised to the hypothermia group; there was biased recording of SAEs in the hypothermia group. We now believe that more adequately powered clinical trials of common therapies used to reduce ICP, such as hypertonic therapy, barbiturates and hyperventilation, are required to assess their potential benefits and risks to patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN34555414. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 45. See the NIHR Journals Library website for further project information. The European Society of Intensive Care Medicine supported the pilot phase of this trial.
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Affiliation(s)
- Peter Jd Andrews
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - H Louise Sinclair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Aryelly Rodríguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Bridget Harris
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Gordon Murray
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Gobatto ALN, Link MA, Solla DJ, Bassi E, Tierno PF, Paiva W, Taccone FS, Malbouisson LM. Transfusion requirements after head trauma: a randomized feasibility controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:89. [PMID: 30871608 PMCID: PMC6419414 DOI: 10.1186/s13054-018-2273-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/22/2018] [Indexed: 02/02/2023]
Abstract
Background Anemia is frequent among patients with traumatic brain injury (TBI) and is associated with an increased risk of poor outcome. The optimal hemoglobin concentration to trigger red blood cell (RBC) transfusion in patients with TBI is not clearly defined. Methods All eligible consecutive adult patients admitted to the intensive care unit (ICU) with moderate or severe TBI were randomized to a “restrictive” (hemoglobin transfusion threshold of 7 g/dL), or a “liberal” (threshold 9 g/dL) transfusion strategy. The transfusion strategy was continued for up to 14 days or until ICU discharge. The primary outcome was the mean difference in hemoglobin between groups. Secondary outcomes included transfusion requirements, intracranial pressure management, cerebral hemodynamics, length of stay, mortality and 6-month neurological outcome. Results A total of 44 patients were randomized, 21 patients to the liberal group and 23 to the restrictive group. There were no baseline differences between the groups. The mean hemoglobin concentrations during the 14-day period were 8.4 ± 1.0 and 9.3 ± 1.3 (p < 0.01) in the restrictive and liberal groups, respectively. Fewer RBC units were administered in the restrictive than in the liberal group (35 vs. 66, p = 0.02). There was negative correlation (r = − 0.265, p < 0.01) between hemoglobin concentration and middle cerebral artery flow velocity as evaluated by transcranial Doppler ultrasound and the incidence of post-traumatic vasospasm was significantly lower in the liberal strategy group (4/21, 3% vs. 15/23, 65%; p < 0.01). Hospital mortality was higher in the restrictive than in the liberal group (7/23 vs. 1/21; p = 0.048) and the liberal group tended to have a better neurological status at 6 months (p = 0.06). Conclusions The trial reached feasibility criteria. The restrictive group had lower hemoglobin concentrations and received fewer RBC transfusions. Hospital mortality was lower and neurological status at 6 months favored the liberal group. Trial registration ClinicalTrials.gov, NCT02203292. Registered on 29 July 2014. Electronic supplementary material The online version of this article (10.1186/s13054-018-2273-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- André L N Gobatto
- Internal Medicine, Hospital São Rafael, Salvador, Brazil.,Intensive Care Unit, Hospital da Cidade, Salvador, Brazil.,Surgical Intensive Care Unit, Anesthesiology Division, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Milena A Link
- Surgical Intensive Care Unit, Anesthesiology Division, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Davi J Solla
- Division of Neurosurgery, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Estevão Bassi
- Trauma Intensive Care Unit, Surgery Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Paulo F Tierno
- Trauma Intensive Care Unit, Surgery Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Wellingson Paiva
- Division of Neurosurgery, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Brussels, Belgium
| | - Luiz M Malbouisson
- Surgical Intensive Care Unit, Anesthesiology Division, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil. .,Trauma Intensive Care Unit, Surgery Emergency Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.
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45
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Intraoperative Blood and Coagulation Factor Replacement During Neurosurgery. Neurosurg Clin N Am 2018; 29:547-555. [DOI: 10.1016/j.nec.2018.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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46
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Abstract
Purpose of review The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI. Recent findings Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI. Summary Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion.
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47
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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48
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Kisilevsky A, Gelb AW, Bustillo M, Flexman AM. Anaemia and red blood cell transfusion in intracranial neurosurgery: a comprehensive review. Br J Anaesth 2018; 120:988-998. [PMID: 29661416 DOI: 10.1016/j.bja.2017.11.108] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 01/04/2023] Open
Abstract
Both anaemia and blood transfusion are associated with poor outcomes in the neurosurgical population. Based on the available literature, the optimal haemoglobin concentration for neurologically injured patients appears to be in the range of 9.0-10.0 g dl-1, although the individual risks and benefits should be weighed. Several perioperative blood conservation strategies have been used successfully in neurosurgery, including correction of anaemia and coagulopathy, use of antifibrinolytics, and intraoperative cell salvage. Avoidance of non-steroidal anti-inflammatory drugs and starch-containing solutions is recommended given the potential for platelet dysfunction.
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Affiliation(s)
- A Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - M Bustillo
- Department of Anesthesiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - A M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada.
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49
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Litofsky NS, Miller DC, Chen Z, Simonyi A, Klakotskaia D, Giritharan A, Feng Q, McConnell D, Cui J, Gu Z. Anaemia worsens early functional outcome after traumatic brain injury: a preliminary study. Brain Inj 2018; 32:342-349. [DOI: 10.1080/02699052.2018.1425913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- N Scott Litofsky
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Douglas C Miller
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO, USA
| | - Zhenzhou Chen
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO, USA
| | - Agnes Simonyi
- Department of Biochemistry, University of Missouri School of Medicine, Columbia, MO, USA
| | - Diana Klakotskaia
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Andrew Giritharan
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO, USA
| | - Qi Feng
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Diane McConnell
- Division of Neurological Surgery, University of Missouri School of Medicine, Columbia, MO, USA
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO, USA
| | - Jiankun Cui
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO, USA
| | - Zezong Gu
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO, USA
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50
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Carteron L, Bouzat P, Oddo M. Cerebral Microdialysis Monitoring to Improve Individualized Neurointensive Care Therapy: An Update of Recent Clinical Data. Front Neurol 2017; 8:601. [PMID: 29180981 PMCID: PMC5693841 DOI: 10.3389/fneur.2017.00601] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/27/2017] [Indexed: 01/04/2023] Open
Abstract
Cerebral microdialysis (CMD) allows bedside semicontinuous monitoring of patient brain extracellular fluid. Clinical indications of CMD monitoring are focused on the management of secondary cerebral and systemic insults in acute brain injury (ABI) patients [mainly, traumatic brain injury (TBI), subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)], specifically to tailor several routine interventions—such as optimization of cerebral perfusion pressure, blood transfusion, glycemic control and oxygen therapy—in the individual patient. Using CMD as clinical research tool has greatly contributed to identify and better understand important post-injury mechanisms—such as energy dysfunction, posttraumatic glycolysis, post-aneurysmal early brain injury, cortical spreading depressions, and subclinical seizures. Main CMD metabolites (namely, lactate/pyruvate ratio, and glucose) can be used to monitor the brain response to specific interventions, to assess the extent of injury, and to inform about prognosis. Recent consensus statements have provided guidelines and recommendations for CMD monitoring in neurocritical care. Here, we summarize recent clinical investigation conducted in ABI patients, specifically focusing on the role of CMD to guide individualized intensive care therapy and to improve our understanding of the complex disease mechanisms occurring in the immediate phase following ABI. Promising brain biomarkers will also be described.
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Affiliation(s)
- Laurent Carteron
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besançon, University of Bourgogne - Franche-Comté, Besançon, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, University Hospital Grenoble, Grenoble, France
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
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