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Non-pharmacological interventions in traumatic
brain injury: an updateDr Matt Wiles
Department of Neuroanaesthesia & Neurocritical Care
Sheffield Teaching Hospitals NHS Foundation Trust, UK
@STHJournalClubsthjournalclub.wordpress.comwww.researcherid.com/rid/F-5612-2015
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“….there are known knowns; there are things we know we know.
We also know there are known unknowns; that is to say we know there are some things we do not know.
But there are also unknown unknowns – the ones we don't know we don't know.”
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Parameter BTF EBIC AAGBI
Respiratory AVOIDSpO2 <90%PaO2 <8 kPaPaCO2 <3.3 kPa
TARGETSpO2 >95%PaO2 >10 kPaPaCO2 4.0-4.5 kPa
TARGET
PaO2 >13 kPaPaCO2 4.5-5.0 kPa
Cardiovascular AVOIDSBP <90mmHg
TARGETMAP >90 mmHgSBP >120 mmHg
TARGETMAP >80 mmHg
Neurological ICP <20CPP 50-70 (probably 60)
ICP <20-25CPP 60-70
ICP <20-25CPP 60-70
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Changing TBI Population
Year Number Median age % aged > 50 years
Traumatic Coma Data Bank 1984-1987 746 25 15
UK Four Centre Study 1986-1988 988 29 27
EBIC Core Data Survey 1995 1005 38 33
Rotterdam Cohort Study 1999-2003 774 42 39
Austrian Severe TBI Study 1999-2004 492 48 (mean) 45
TARN Review 2003-2009 15 173 39 (mean) Not reported
Italian TBI Study 2012 1366 45 44
RAIN Study (UK) 2008-2009 2975 44 Not reported
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Objectives
• To examine recent developments in traumatic brain injury with respect to the use of:
• Intracranial pressure monitoring• Decompressive craniectomy• Osmotherapy• Therapeutic targets (MAP) & Fluids• Prognostication tools
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ICP MonitoringChesnut RM et al. A trial of intracranial-pressure monitoring in traumatic brain injury. New England Journal of Medicine 2012; 367: 2471-81.
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ICP MonitoringSu S-H et al. The Effects of Intracranial Pressure Monitoring in Patients with Traumatic Brain Injury. PLoS ONE 2014; 9: e87432.
• Meta-analysis of 9 studies (n=11,038)• ICP monitoring no effect on outcome or mortality• Significant heterogeneity in papers
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ICP MonitoringAlali AS et al. Intracranial Pressure Monitoring in Severe Traumatic Brain Injury: Results from the American College of Surgeons Trauma Quality Improvement Program. Journal of Neurotrauma 2013; 30: 1737–1746.
• n=10,068 with severe TBI• Only 17.6% had ICP monitors
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ICP MonitoringGerber LM et al. Marked reduction in mortality in patients with severe traumatic brain injury. J Neurosurg 2013; 119: 1583–1590.
• Retrospective analysis of severe TBI (2001-2009)• Primarily Level 1 Trauma Centres
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ICP MonitoringKosty JA et al. Brief report: a comparison of clinical and research practices in measuring cerebral perfusion pressure: a literature review and practitioner survey. Anesth Analg 2013; 117: 694-8
• Survey of Neurocritical Care Society• Atrium (74%)• Tragus (16%)• Conflicted (10%)
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ICP MonitoringKosty JA et al. Brief report: a comparison of clinical and research practices in measuring cerebral perfusion pressure: a literature review and practitioner survey. Anesth Analg 2013; 117: 694-8
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https://nasgbi.org.uk/wp-content/uploads/2015/03/Final_Revised_Joint_CPP_statement_Aug_2014.pdf
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ICP MonitoringStocchetti N et al. Clinical applications of intracranial pressure monitoring in traumatic brain injury. Acta Neurochir 2014; 156: 1615–1622
• No ICP bolt:• Normal CT brain
• ICP bolt:• Cerebral contusions and remained sedated• After decompressive craniectomy• After evacuation of supratentorial haematoma and at
risk of raised ICP• GCS ≤ 5, midline shift > 5mm, abnormal pupils etc..
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Decompressive CraniectomyCooper DJ et al. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. New England Journal of Medicine 2011; 364: 1493-1502
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Decompressive CraniectomyHartings JA et al. Surgical management of traumatic brain injury: a comparative-effectiveness study of 2 centers. Journal of Neurosurgery 2014; 120: 434-446.
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CranioplastyBender A et al. Early cranioplasty may improve outcome in neurological patients with decompressive craniectomy. Brain Injury 2013; 27: 1073–79.
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Osmotherapy: MannitolWakai A et al. Mannitol for acute traumatic brain injury. Cochrane Database Syst Rev. 2013; 8: CD001049.
• Only able to identify 4 trials (n=197)• Insufficient reliable evidence to make
recommendations for its use in TBI• Further high-quality RCTs needed despite the
widespread use of mannitol
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Osmotherapy: HTS vs. MannitolRickard AC et al. Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury. Emerg Med J 2013; 31: 679-83.• Six studies (n=171)• Variety of solutions• ICP difference 1.34 mmHg• No outcome measures• More work needed….
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Fluid TherapyCooper DJ et al. Albumin Resuscitation for Traumatic Brain Injury: Is Intracranial Hypertension the Cause of Increased Mortality? Journal of Neurotrauma 2013; 30: 512-8.
• Post hoc analyses of SAFE study (n=321)
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Permissive HypotensionMaas AI et al. Advancing care for traumatic brain injury: findings from the IMPACT studies and perspectives on future research. Lancet Neurol 2013; 12: 1200-10
• Hypotension increases mortality & poor outcomes
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Permissive HypotensionWiles MD. Blood pressure management in trauma: from feast to famine? Anaesthesia 2013; 68: 445–452
• “Trials” of permissive hypotension excluded patients with TBI• Evidence of reduction in haemorrhage with
permissive hypotension is lacking in clinical studies• Much (all) is extrapolated from animal models
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Permissive HypotensionBerry C et al. Redefining hypotension in traumatic brain injury. Injury 2012; 43: 1833–1837
• Retrospective analysis of patients with moderate/severe TBI• North American study (n=15733)
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Permissive HypotensionHassler RM et al. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study. Resuscitation 2012; 83: 476-81
• 3444 patients with penetrating trauma (TARN)
1
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Permissive HypotensionHassler RM et al. Systolic blood pressure below 110 mmHg is associated with increased mortality in blunt major trauma patients: Multicentre cohort study. Resuscitation 2011; 82: 1202-07
• 47 927 patients with blunt trauma (TARN)
1
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Outcome PredictionRoe C et al. Severe traumatic brain injury in Norway: impact of age on outcome. J Rehabil Med 2103; 45: 734-40.
16-64 years(n=156)
≥ 65 years(n=22)
90-day mortality 24% 67%
Returned to own home @ 90 days 53% 68%
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Outcome PredictionStevens RD, Sutter R. Prognosis in severe brain injury. Crit Care Med 2013; 41: 1104-23.
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Outcome PredictionMercier E et al. Predictive value of S-100β protein for prognosis in patients with moderate and severe traumatic brain injury: systematic review and meta-analysis. BMJ 2013; 346: f1757
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Outcome PredictionTurgeon AF et al. Determination of Neurologic Prognosis and Clinical Decision Making in Adult Patients With Severe Traumatic Brain Injury: A Survey of Canadian Intensivists, Neurosurgeons, and Neurologists. Crit Care Med 2013; 41: 1087–1093
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Outcome PredictionTurgeon AF et al. Determination of Neurologic Prognosis and Clinical Decision Making in Adult Patients With Severe Traumatic Brain Injury: A Survey of Canadian Intensivists, Neurosurgeons, and Neurologists. Crit Care Med 2013; 41: 1087–1093
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“The lack of improvement in head injured patients is typified by the apparent overall lack of progress in head injury care, which is suggested by the failure to identify a single therapy to improve outcome despite over 250 randomised controlled trials. However, several studies have shown that the institution of packages of specialist neurosurgical or neurocritical care is associated with improved outcomes.”
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Summary• Therapeutic targets
• Hypotension still bad for brains
• Intracranial pressure monitoring• Just a number but (probably) useful as part of neurocritical
care package
• Decompressive craniectomy• Size may matter; await RESCUEICP
• Osmotherapy• HTS or mannitol will lower ICP but not alter outcomes
• Prognostication• S-100β protein shows promise
