Skip to main content Accessibility help
×
Hostname: page-component-848d4c4894-xm8r8 Total loading time: 0 Render date: 2024-06-22T09:38:08.922Z Has data issue: false hasContentIssue false

Chapter 13 - Therapeutic Options in Neurocritical Care

Optimising Brain Physiology

Published online by Cambridge University Press:  28 April 2020

Peter C. Whitfield
Affiliation:
Derriford Hospital, Plymouth
Jessie Welbourne
Affiliation:
University Hospitals, Plymouth
Elfyn Thomas
Affiliation:
Derriford Hospital, Plymouth
Fiona Summers
Affiliation:
Aberdeen Royal Infirmary
Maggie Whyte
Affiliation:
Aberdeen Royal Infirmary
Peter J. Hutchinson
Affiliation:
Addenbrooke’s Hospital, Cambridge
Get access

Summary

Traumatic Brain Injury (TBI) is a major cause of mortality and morbidity. The severity of primary injury is the major determinant of outcome and occurs during the initial insult, as result of displacement of the physical structures of the brain. However, several factors can occur in the post-injury phase and have also been independently demonstrated to contribute to ‘secondary brain injury’ and to worsen patients’ outcome. These include intracranial hypertension, systemic hypotension, hypoxemia, hyperpyrexia, hypocapnoea and hyper- and hypoglycaemia; many of these factors are amenable to clinical manipulation. It is not well understood how much primary and secondary injuries respectively contribute towards the clinical manifestations of TBI. The exact mechanisms leading to secondary brain injury are not fully elucidated, but exacerbation of cerebral ischaemia and cerebral hypoperfusion are thought to be crucial factors. The integrated management of these factors forms the basis for specialist neurocritical care.

Type
Chapter
Information
Traumatic Brain Injury
A Multidisciplinary Approach
, pp. 146 - 163
Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Elf, K, Nilsson, P, Enblad, P. Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med 2002;30(9):2129–34.Google Scholar
Patel, HC, Menon, DK, Tebbs, S, Hawker, R, Hutchinson, PJ, Kirkpatrick, PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med 2002;28(5):547–53.Google Scholar
Clayton, TJ, Nelson, RJ, Manara, AR. Reduction in mortality from severe head injury following introduction of a protocol for intensive care management. Br J Anaesth 2004;93(6):761–7.CrossRefGoogle ScholarPubMed
Patel, HC, Bouamra, O, Woodford, M, King, AT, Yates, DW, Lecky, FE. Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2005;366(9496):1538–44. Erratum in Lancet 2006;367(9513):816.Google Scholar
Rosner, MJ, Rosner, SD, Johnson, AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 1995;83(6):949–62.CrossRefGoogle ScholarPubMed
Eker, C, Asgeirsson, B, Grände, PO, Schalén, W, Nordström, CH. Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation. Intensive Care Med 2006;32(10):1475–84.Google Scholar
Grände, PO. The ‘Lund Concept’ for the treatment of patients with severe traumatic brain injury. J Neurosurg Anesthesiol 2011;23(4):358–62.Google ScholarPubMed
Asgeirsson, B, Grände, PO, Nordström, CH. A new therapy of post-trauma brain oedema based on haemodynamic principles for brain volume regulation. Intensive Care Med 1994;20(4):260–7.CrossRefGoogle ScholarPubMed
Grände, PO, Asgeirsson, B, Nordström, CH. Volume-targeted therapy of increased intracranial pressure: the Lund concept unifies surgical and non-surgical treatments. Acta Anaesthesiol Scand 2002;46(8):929–41.Google Scholar
Grande, PO, Möller, AD, Nordström, CH, Ungerstedt, U. Low-dose prostacyclin in treatment of severe brain trauma evaluated with microdialysis and jugular bulb oxygen measurements. Acta Anaesthesiol Scand 2000;44(7):886–94.CrossRefGoogle ScholarPubMed
Eker, C, Asgeirsson, B, Grände, PO, Schalén, W, Nordström, CH. Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation. Intensive Care Med 2006;32(10):1475–84.Google Scholar
Naredi, S, Olivecrona, M, Lindgren, C, Ostlund, AL, Grände, PO, Koskinen, LO. An outcome study of severe traumatic head injury using theLund therapy’ with low-dose prostacyclin. Acta Anaesthesiol Scand 2001;45(4):402–6.Google Scholar
Elf, K, Nilsson, P, Ronne-Engström, E, Howells, T, Enblad, P. Cerebral perfusion pressure between 50 and 60 mm Hg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Neurosurgery 2005;56(5):962–71.Google ScholarPubMed
Chesnut, RM, Marshall, LF, Klauber, MR, Blunt, BA, Baldwin, N, Eisenberg, HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34(2):216–22.Google Scholar
Chesnut, RM, Marshall, SB, Piek, J, Blunt, BA, Klauber, MR, Marshall, LF. Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir Suppl 1993;59:121–5.Google Scholar
Clifton, GL, Miller, ER, Choi, SC, Levin, HS. Fluid thresholds and outcome from severe brain injury. Crit Care Med 2002;30(4):739–45.Google Scholar
Aries, MJ, Czosnyka, M, Budohoski, KP, Steiner, LA, Lavinio, A, Kolias, AG, et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med 2012;40(8):2456–63.CrossRefGoogle ScholarPubMed
Carney, N, Totten, AM, OʼReilly, C, Ullman, JS, Hawryluk, GW, Bell, MJ, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery 2017 Jan 1;80(1):6-15.CrossRefGoogle ScholarPubMed
Gupta, AK, Hutchinson, PJ, Al-Rawi, P, Gupta, S, Swart, M, Kirkpatrick, PJ, Menon, DK, Datta, AK. Measuring brain tissue oxygenation compared with jugular venous oxygen saturation for monitoring cerebral oxygenation after traumatic brain injury. Anesth Analg 1999;88(3):549–53.Google Scholar
Coles, JP, Fryer, TD, Smielewski, P, Chatfield, DA, Steiner, LA, Johnston, AJ, et al. Incidence and mechanisms of cerebral ischemia in early clinical head injury. J Cereb Blood Flow Metab 2004;24(2):202–11.CrossRefGoogle ScholarPubMed
Coles, JP, Fryer, TD, Smielewski, P, Rice, K, Clark, JC, Pickard, JD, Menon, DK. Defining ischemic burden after traumatic brain injury using 15O PET imaging of cerebral physiology. J Cereb Blood Flow Metab 2004;24(2):191201.Google Scholar
Czosnyka, M, Smielewski, P, Kirkpatrick, P, Menon, DK, Pickard, JD. Monitoring of cerebral autoregulation in head-injured patients. Stroke 1996;27(10):1829–34.Google Scholar
Howells, T, Elf, K, Jones, PA, Ronne-Engström, E, Piper, I, Nilsson, P, Andrews, P, Enblad, P. Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 2005;102(2):311–17.Google Scholar
Bratton, SL, Chestnut, RM, Ghajar, J, McConnell Hammond, FF, Harris, OA, Hartl, R, et al. Guidelines for the management of severe traumatic brain injury. XIV. Hyperventilation. J Neurotrauma 2007;24(Suppl 1):S8790.Google Scholar
Muizelaar, JP, Marmarou, A, Ward, JD, Kontos, HA, Choi, SC, Becker, DP, Gruemer, H, Young, HF. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991;75(5):731–9.Google Scholar
Moppett, IK, Sherman, RW, Wild, MJ, Latter, JA, Mahajan, RP. Effects of norepinephrine and glyceryl trinitrate on cerebral haemodynamics: transcranial Doppler study in healthy volunteers. Br J Anaesth 2008;100(2):240–4.Google Scholar
Talmor, D, Shapira, Y, Artru, AA, Gurevich, B, Merkind, V, Katchko, L, Reichenthal, E. 0.45% saline and 5% dextrose in water, but not 0.9% saline or 5% dextrose in 0.9% saline, worsen brain edema two hours after closed head trauma in rats. Anesth Analg 1998;86(6):1225–9.Google Scholar
Oddo, M, Milby, A, Chen, I, Frangos, S, MacMurtrie, E, Maloney-Wilensky, E, et al. Hemoglobin concentration and cerebral metabolism in patients with aneurysmal subarachnoid hemorrhage. Stroke 2009;40(4):1275–81.Google Scholar
Sekhon, MS, McLean, N, Henderson, WR, Chittock, DR, Griesdale, DE.Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic brain injury. Crit Care 2012;16(4):R128.Google Scholar
Helmy, A, Carpenter, KL, Hutchinson, PJ. Microdialysis in the human brain and its potential role in the development and clinical assessment of drugs. Curr Med Chem 2007;14(14):1525–37.Google Scholar
Stocchetti, N, Maas, AI. Traumatic intracranial hypertension. N Engl J Med 2014;371(10):972.Google Scholar
Citerio, G, Cormio, M. Sedation in neurointensive care: advances in understanding and practice. Curr Opin Crit Care 2003;9(2):120–6.Google Scholar
Johnston, AJ, Steiner, LA, Chatfield, DA, Coleman, MR, Coles, JP, Al-Rawi, PG, Menon, DK, Gupta, AK. Effects of propofol on cerebral oxygenation and metabolism after head injury. Br J Anaesth 2003;91(6):781–6.Google Scholar
Karabinis, A, Mandragos, K, Stergiopoulos, S, Komnos, A, Soukup, J, Speelberg, B, Kirkham, AJ. Safety and efficacy of analgesia-based sedation with remifentanil versus standard hypnotic-based regimens in intensive care unit patients with brain injuries: a randomised, controlled trial. Crit Care 2004;8(4):R268–80.Google Scholar
Krajčová, A, Waldauf, P, Anděl, M, Duška, F. Propofol infusion syndrome: a structured review of experimental studies and 153 published case reports. Crit Care 2015;19: 398.Google Scholar
Fleischer, JE, Milde, JH, Moyer, TP, Michenfelder, JD. Cerebral effects of high-dose midazolam and subsequent reversal with Ro 15–1788 in dogs. Anesthesiology 1988;68(2):234–42.Google Scholar
Hocker, SE, Fogelson, J, Rabistein, AA. Refractory intracranial hypertension due to fentanyl administration following closed head injury. Front Neurol 2013; 4:3.CrossRefGoogle ScholarPubMed
Sheth, RD, Gidal, BE. Refractory status epilepticus: response to ketamine. Neurology 1998;51(6):1765–6.Google Scholar
Kolenda, H, Gremmelt, A, Rading, S, Braun, U, Markakis, E. Ketamine for analgosedative therapy in intensive care treatment of head-injured patients. Acta Neurochir (Wien) 1996;138(10):1193–9. Erratum in: Acta Neurochir (Wien) 1997;139(12):1193.Google Scholar
Filanovsky, Y, Miller, P, Kao, J. Myth: ketamine should not be used as an induction agent for intubation in patients with head injury. CJEM 2010;12(2):154–7.Google Scholar
Slutsky, AS, Ranieri, VM. Mechanical ventilation: lessons from the ARDSNet trial. Respir Res 2000;1(2):73–7.Google Scholar
Neto, AS, Simonis, FD, Barbas, CS, Biehl, M, Determann, RM, Elmer, J, et al. Lung-protective ventilation with low tidal volumes and the occurrence of pulmonary complications in patients without acute respiratory distress syndrome: a systematic review and individual patient data analysis. Crit Care Med 2015;43(10):2155–63.CrossRefGoogle ScholarPubMed
Borsellino, B, Schultz, MJ, Gama de Abreu, M, Robba, C, Bilotta, F. Mechanical ventilation in neurocritical care patients: a systematic literature review. Expert Rev Respir Med 2016;10(10):1123–32.Google Scholar
Coles, JP, Fryer, TD, Coleman, MR, Smielewski, P, Gupta, AK, Minhas, PS, et al. Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 2007;35(2):568–78.Google Scholar
Grubb, RL Jr, Raichle, ME, Eichling, JO, et al. The effects of changes in PaCO2 on cerebral blood volume, blood flow, and vascular mean transit time. Stroke 1974;5:630–9.CrossRefGoogle ScholarPubMed
Serpa Neto, A, Filho, RR, Cherpanath, T, Determann, R, Dongelmans, DA, Paulus, F, et al. Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials. Ann Intensive Care 2016;6(1):109.Google Scholar
Lovas, A, Szakmány, T. Haemodynamic effects of lung recruitment manoeuvres. Biomed Res Int 2015;2015:478970.Google Scholar
Robba, C, Bragazzi, NL, Bertuccio, A, Cardim, D, Donnelly, J, Sekhon, M, et al. Effects of prone position and positive end-expiratory pressure on noninvasive estimators of ICP: a pilot study. J Neurosurg Anesthesiol 2016;29.Google Scholar
Thelandersson, A, Cider, A, Nellgård, B. Prone position in mechanically ventilated patients with reduced intracranial compliance. Acta Anaesthesiol Scand 2006;50(8):937–41.Google Scholar
Guérin, C, Reignier, J, Richard, JC, Beuret, P, Gacouin, A, Boulain, T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368(23):2159–68.Google Scholar
Ropper, AH. Hyperosmolar therapy for raised intracranial pressure. N Eng J Med 2012;367(8):746–52.Google Scholar
Nath, F, Galbraith, S. The effect of mannitol on cerebral white matter water content. J Neurosurg 1986;65(1):41–3.Google Scholar
Bullock, R. Mannitol and other diuretics in severe neurotrauma. New Horiz 1995;3(3):448–52.Google Scholar
Manninen, PH, Lam, AM, Gelb, AW, Brown, SC. The effect of high-dose mannitol on serum and urine electrolytes and osmolality in neurosurgical patients. Can J Anaesth 1987;34(5):442–6.Google Scholar
Rallis, D, Poulos, P, Kazantzi, M, Chalkias, A, Kalampalikis, P. Effectiveness of 7.5% hypertonic saline in children with severe traumatic brain injury. J Crit Care 2016;38:52–6.Google Scholar
Burgess, S, Abu-Laban, RB, Slavik, RS, Vu, EN, Zed, PJ. A systematic review of randomized controlled trials comparing hypertonic sodium solutions and mannitol for traumatic brain injury: implications for emergency department management. Ann Pharmacother 2016;50(4):291300.Google Scholar
Vialet, R, Albanèse, J, Thomachot, L, Antonini, F, Bourgouin, A, Alliez, B, Martin, C. Isovolume hypertonic solutes (sodium chloride or mannitol) in the treatment of refractory posttraumatic intracranial hypertension: 2 mL/kg 7.5% saline is more effective than 2 mL/kg 20% mannitol. Crit Care Med 2003;31(6):1683–7.Google Scholar
Horn, P, Münch, E, Vajkoczy, P, Herrmann, P, Quintel, M, Schilling, L, Schmiedek, P, Schürer, L. Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates. Neurol Res 1999;21(8):758–64.Google Scholar
Qureshi, AI, Suarez, JI. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension. Crit Care Med 2000;28(9):3301–13.CrossRefGoogle ScholarPubMed
Suehiro, E, Fujisawa, H, Ito, H, Ishikawa, T, Maekawa, T. Brain temperature modifies glutamate neurotoxicity in vivo. J Neurotrauma 1999;16(4):285–97.Google Scholar
Kimura, A, Sakurada, S, Ohkuni, H, Todome, Y, Kurata, K. Moderate hypothermia delays proinflammatory cytokine production of human peripheral blood mononuclear cells. Crit Care Med 2002;30(7):1499–502.CrossRefGoogle ScholarPubMed
Clifton, GL, Allen, S, Barrodale, P, Plenger, P, Berry, J, Koch, S, Fletcher, J, Hayes, RL, Choi, SC. A phase II study of moderate hypothermia in severe brain injury. J Neurotrauma 1993;10(3):263–71.Google Scholar
Marion, DW, Penrod, LE, Kelsey, SF, Obrist, WD, Kochanek, PM, Palmer, AM, Wisniewski, SR, DeKosky, ST. Treatment of traumatic brain injury with moderate hypothermia. N Eng J Med 1997;336(8):540–6.Google Scholar
Clifton, GL, Miller, ER, Choi, SC, Levin, HS, McCauley, S, Smith, KR Jr, et al. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 2001;344(8):556–63.Google Scholar
Andrews, PJD, Sinclair, L, Rodriguez, A, Harris, BA, Battison, CG, Rhodes, JKJ, Murray, GD. Hypothermia of intracranial hypertension after traumatic brain injury. N Engl J Med 2015;373:2403–12.Google Scholar
Polderman, KH, Ely, EW, Badr, AE, Girbes, AR. Induced hypothermia in traumatic brain injury: considering the conflicting results of meta-analyses and moving forward. Intensive Care Med 2004;30(10):1860–4.Google Scholar
Polderman, KH. Application of therapeutic hypothermia in the ICU: opportunities and pitfalls of a promising treatment modality. Part 1: Indications and evidence. Intensive Care Med 2004;30(4):556–75.Google Scholar
Cook, CJ. Induced hypothermia in neurocritical care: a review. J Neurosci Nurs 2017;49(1):511.CrossRefGoogle ScholarPubMed
Polderman, KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 2009;37(7 Suppl):S186202.Google Scholar
Polderman, KH, Herold, I. Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med 2009;37(3):1101–20.Google Scholar
Helmy, A, Vizcaychipi, M, Gupta, AK. Traumatic brain injury: intensive care management. Br J Anaesth 2007;99(1):3242.Google Scholar
Shein, SL, Ferguson, NM, Kochanek, PM, Bayir, H, Clark, RS, Fink, EL, et al. Effectiveness of pharmacological therapies for intracranial hypertension in children with severe traumatic brain injury – results from an automated data collection system time-synched to drug administration. Pediatr Crit Care Med 2016;17(3):236–45.Google Scholar
Goodman, JC, Valadka, AB, Gopinath, SP, Cormio, M, Robertson, CS. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients. J Neurotrauma 1996;13(10):549–56.Google Scholar
Schwartz, ML, Tator, CH, Rowed, DW, Reid, SR, Meguro, K, Andrews, DF. The University of Toronto head injury treatment study: a prospective, randomized comparison of pentobarbital and mannitol. Can J Neurol Sci 1984;11(4):434–40.Google Scholar
Roberts, I, Sydenham, E. Barbiturates for acute traumatic brain injury. Cochrane Database Syst Rev 2012;12:CD000033.Google Scholar
Bullock, MR, Chesnut, R, Ghajar, J, Gordon, D, Hartl, R, Newell, DW, Servadei, F, Walters, BC, Wilberger, JE. Surgical management of acute subdural hematomas. Neurosurgery 2006;58(3 Suppl):S1624.Google Scholar
Bullock, MR, Chesnut, R, Ghajar, J, Gordon, D, Hartl, R, Newell, DW, Servadei, F, Walters, BC, Wilberger, JE. Surgical management of acute epidural hematomas. Neurosurgery 2006;58(3 Suppl): S715.Google ScholarPubMed
Bullock, MR, Chesnut, R, Ghajar, J, Gordon, D, Hartl, R, Newell, DW, Servadei, F, Walters, BC, Wilberger, J. Surgical management of traumatic parenchymal lesions.Neurosurgery 2006;58(3 Suppl):S2546.Google Scholar
Mendelow, AD, Gregson, BA, Rowan, EN, Murray, GD, Gholkar, A, Mitchell, PM, STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013;382(9890):397408.Google Scholar
Gregson, BA, Rowan, EN, Mitchell, PM, Unterberg, A, McColl, EM, Chambers, IR, McNamee, P, Mendelow, AD. Surgical trial in traumatic intracerebral hemorrhage (STITCH(Trauma)): study protocol for a randomized controlled trial. Trials 2012;13:193.Google Scholar
Cooper, DJ, Rosenfeld, JV, Murray, L, Arabi, YM, Davies, AR, D’Urso, P, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011;364(16):1493–502.Google Scholar
Hutchinson, PJ, Kolias, AG, Timofeev, IS, Corteen, EA, Czosnyka, M, Timothy, J, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 2016;375(12):1119–30.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×