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The condition of patients with severe traumatic brain injury (sTBI) complicated by corona virus 2019 disease (COVID-19) is complex. sTBI can significantly increase the probability of COVID-19 developing into severe or critical stage, while COVID-19 can also increase the surgical risk of sTBI and the severity of postoperative lung lesions. There are many contradictions in the treatment process, which brings difficulties to the clinical treatment of such patients. Up to now, there are few clinical studies and therapeutic norms relevant to sTBI complicated by COVID-19. In order to standardize the clinical treatment of such patients, Critical Care Medicine Branch of China International Exchange and Promotive Association for Medical and Healthcare and Editorial Board of Chinese Journal of Trauma organized relevant experts to formulate the Chinese expert consensus on clinical treatment of adult patients with severe traumatic brain injury complicated by corona virus infection 2019 ( version 2023) based on the joint prevention and control mechanism scheme of the State Council and domestic and foreign literatures on sTBI and COVID-19 in the past 3 years of the international epidemic. Fifteen recommendations focused on emergency treatment, emergency surgery and comprehensive management were put forward to provide a guidance for the diagnosis and treatment of sTBI complicated by COVID-19.
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Objective:To analyze the indication and status of early use of analgesic, sedative and antiepileptic drugs of patients with traumatic brain injury (TBI) admitted to the neurological intensive care unit (NICU).Methods:A questionnaire covering hospital basic characteristics, prehospital and emergency care, inpatient treatment, neurocritical care and rehabilitation were used to survey NICU of 37 hospitals in 18 municipalities or provinces from the Chinese registry of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) by Web or Email. The indications for admission to the NICU, categories and frequency of early use of analgesic and sedative drugs, and categories, frequency and indications of early use of antiepileptic drugs were analyzed.Results:Glasgow coma scale (GCS)≤8 points in patients with TBI and post-operation of TBI were the main indications for admission in 30 NICU (81.1%) and 24 NICU (64.9%), respectively. When admitting patients with a GCS of 9-12 points or 13-15 points, most NICU gave more considerations to the combined other risk factors. In terms of the early use of analgesics and sedatives, fentanyl was routinely used for analgesia (i.e., use frequency for 70%-100%) in 13 NICU (35.1%), and midazolam and alpha-2 agonists were routinely used for sedation in 24 NICU (64.9%) and 18 NICU (48.6%), respectively. Regarding the early use of antiepileptic drugs, sodium valproate was routinely used in 35 NICU (94.6%). Moreover, seizures within 2 hours after injury, penetrating TBI and cortical contusion were indications for routine application of antiepileptic drugs in 35 NICU (94.6%), 21 NICU (56.8%) and 20 NICU (54.1%), respectively.Conclusions:Severe TBI and post-operation of TBI are the main indications for admission to the NICU, while the combination of other risk factors will be considered when admitting patients with moderate or mild TBI. For TBI patients admitted to NICU, fentanyl, midazolam and sodium valproate are the most commonly used analgesic, sedative, and antiepileptic drugs in the early stage. Seizures within 2 hours after injury, penetrating TBI and cortical contusion are the main indications for antiepileptic drug use.
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Objective:To investigate the effect of cranioplasty with polyetheretherketone (PEEK) after craniectomy in patients with traumatic brain injury (TBI).Methods:A retrospective case series study was used to analyze the clinical data of 85 TBI patients undergone craniectomy admitted to Renji Hospital, Shanghai Jiaotong University School of Medicine from February 2017 to April 2021, including 57 males and 28 females, aged 7-70 years [(40.8±15.5)years]. Patients′ Glasgow Coma Scale (GCS) was 6-15 points [15 (13, 15)points]. All patients underwent PEEK cranioplasty as scheduled. The extended Glasgow Outcome Scale (GOSE) was used to evaluate the neurological function before, at 3 and 6 months after operation. After excluding 33 patients with preoperative GOSE score of 8 points, 52 patients with preoperative GOSE score less than 8 points were analyzed on the degree of GOSE improvement. Patients′ satisfaction with PEEK repair was evaluated through telephone interviews at 6 months postoperatively. The incidence of complications were observed during hospitalization and within 6 months postoperatively.Results:All patients were followed up for 6-7 months [6 (6, 7)months]. The GOSE was 6 (5, 8)points before operation, 6 (5, 8)points at 3 months after operation, and 7 (5, 8)points at 6 months after operation. There was no significant difference in GOSE at 3 months after operation and before operation ( P>0.05), but it was significantly increased at 6 months after operation when compared to the preoperative level ( P<0.05). With regards to GOSE, there were 10 patients with mild amelioration but 42 with no amelioration at 3 months after operation, while 4 patients with significant amelioration and 31 with no amelioration were observed at 6 months after operation ( P<0.05). For PEEK repair, Patients′ satisfaction was very high in 43 patients, high in 33, general in 7 and poor in 2. A total of 25 patients had postoperative complications during hospitalization and within 6 months postoperatively, with the incidence of complications of 29%. Specifically, there was 1 patient with wound infection, 1 new epilepsy, 8 epidural hemorrhage, 13 subcutaneous effusion, 1 subcutaneous effusion, severe infection and material exposure, and 1 severe infection, new-onset epilepsy and subcutaneous effusion. Repair materials were removed in 2 patients due to multiple complications; other patients obtained alleviation via treatment, without affect on their daily life. Conclusion:PEEK cranioplasty following craniectomy for TBI patients can improve prognosis, attain high satisfaction and has low incidences of postoperative infection and exposure of repair materials.
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Patients with coma caused by traumatic brain injury ( TBI) suffer from poor quality of life and many complications, which brings heavy burden to their families. The exploration of TBI treatment will help patients restore function, reduce disability rate and improve quality of life. At present, the clinical treatment of TBI mainly includes mild hypothermia treatment, hyperbaric oxygen treatment, awakening drugs and median nerve electrical stimulation, which have their own limitations. Currently, a number of studies have focused on the application of vagus nerve stimulation ( VNS) in TBI. The possible mechanisms of VNS include anti-inflammatory effect, brain edema reduction and stabilization of intracranial pressure, promoting nerve function recovery, attenuation of blood-brain barrier breakdown, glutamate-mediated excitotoxicity, synaptic plasticity and recruitment of endogenous neural stem cells. VNS can be used as a new method of clinical treatment for patients with TBI, but it also carries risks of complication as an invasive electrical stimulation. The author summarizes the usage, possible mechanism and safety of VNS, so as to provide reference for further understanding the application of VNS in TBI treatment.
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Objective To explore the major differences of the provider profiles in terms of structural characteristics, hospital facilities and workflow of traumatic brain injury ( TBI) centers between China and European Union and compare the efficacy. Methods The questionnaires were designed focusing on the provider profiling, and 45 Chinese centers and 71 European centers were recruited into Collaborative European NeuroTrauma Effectiveness Research in TBI ( CENTER-TBI) program. The structural characteristics, hospital facilities and work flow of the two groups were compared. Results The proportion of helicopter platform facilities[31％ (14/45)] : 80％ (57/71)]in China group was lower than that in European Union group (P <0. 01), while the proportion of neurological ICU facilities [98％ (44/45) : 57％ (40/71)] in China group was higher than that in European Union group (P <0. 01). China group has higher ratios in all-day trauma operation room [96％(43/45):75％(53/71)], open ICU [27％(12/45):4％(3/71)], transitional beds[93％(42/45):71％(50/71)] than those in European Union group (P<0.01). European Union group had higher ratios in implementing brain parenchymal intracranial pressure monitoring [31％ (21/67) :7％ (344)] and adopting 20 mmHg as the threshold of intracranial hypertension [86％(57/66):64％(29/45)](P<0.01). The China group adopted more basic life support and followed the US TBI guidelines for clinical management. Conclusions Significant differences are disclosed upon TBI centers between China and EU, mainly demonstrated in neurological ICU facilities, all-day trauma operation room, brain parenchymal intracranial pressure monitoring, and the threshold of intracranial hypertension management. These differences provide a working analysis basis for further comparative studies in the field of TBI and for determining the best clinical practice.
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The vegetative state is a complex condition with unclear mechanisms and limited diagnostic, prognostic, and therapeutic methods. In this study, we aimed to explore the proteomic profile of tears from patients in a traumatic vegetative state and identify potential diagnostic markers using tears-a body fluid that can be collected non-invasively. Using iTRAQ quantitative proteomic technology, in the discovery phase, tear samples collected from 16 patients in a traumatic vegetative state and 16 normal individuals were analyzed. Among 1080 identified tear proteins, 57 were upregulated and 15 were downregulated in the patients compared to the controls. Bioinformatics analysis revealed that the differentially-expressed proteins were mainly involved in the wound response and immune response signaling pathways. Furthermore, we verified the levels of 7 differentially-expressed proteins in tears from 50 traumatic vegetative state patients and 50 normal controls (including the samples used in the discovery phase) using ELISA. The results showed that this 7-protein panel had a high discrimination ability for traumatic vegetative state (area under the curve = 0.999). In summary, the altered tear proteomic profile identified in this study provides a basis for potential tear protein markers for diagnosis and prognosis of the traumatic vegetative state and also provides novel insights into the mechanisms of traumatic vegetative state.
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Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Young Adult , Biomarkers , Metabolism , Chromatography, Liquid , Enzyme-Linked Immunosorbent Assay , Eye Proteins , Metabolism , Mass Spectrometry , Persistent Vegetative State , Metabolism , Proteome , Proteomics , ROC Curve , Tears , MetabolismABSTRACT
Objective To observe the dynamic changes of the power parameters of each frequency band of electroencephalography during the postoperative sedation process of traumatic brain injuries (TBI) to evaluate the values of EEG power in assessing sedation depth.Methods A retrospective case series study was conducted on the clinical postoperative data of 42 patients with TBI from February 2017 to January 2018.There were 22 males and 20 females,aged (39.8 ± 5.3)years (range,25-66 years).Before the sedation,the Glasgow Coma Scale (GCS) was (9.2 ± 2.3)points,ranging from 8 to 12 points.Before the administration of dexmedetomidine (Dex) and 10,30,60,90 minutes after the medication,the body temperature,respiration,heart rate,oxygen saturation (SpO2),and mean arterial pressure (MAP) were recorded and evaluated by Ricker sedation agitation score (SAS).At the same time,the EEG power value changes of four frequency bands (α,β,θ,and δ) were recorded constantly.Correlation analysis was performed between the changing power values and corresponding SAS.Results (1) During sedation,the body temperature,respiration,heart rate,SpO2 and MAP did not show significant fluctuation along with the decrease of SAS (P ＞ 0.01).(2) Before and after Dex sedation,the electroencephalography power value of the delta band was negatively correlated with SAS,with the correlation coefficient absolute value between 0.85 and 0.88 (P ＜ 0.01).The highest absolute value of the correlation coefficient was that of the left frontal and of the right frontal region (0.88,P ＜0.01).The absolute value of the correlation coefficient between (θ + δ)/(α + β) and SAS was between 0.75 and 0.85 (P ＜ 0.01).(3) The fast wave power (α and β band) in each brain area before sedation increased to varied degrees after the sedation,but it decreased along with the falling SAS.The absolute value of correlation coefficient between the electroencephalography power value in α and β band ranged from 0.29 to 0.48 (P ＜ 0.01),indicating weak correlation.There was no significant correlation between the EEG values in the θ band and SAS (P ＞ 0.01).Conclusions The electroencephalography power values of the δ band of each brain region are negatively correlated with SAS and can objectively reflect the dynamic changes of the sedation depth.The absolute values of correlation coefficient between bilateral frontal δ band power and SAS can serve as a better guide for clinical sedation.
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Objective To investigate the feasibility and clinical effect of tranexamic acid in prehospital emergency care of patients with craniocerebral trauma.Methods A randomized,placebo controlled trial was carried out on 77 craniocerebral trauma patients [Glasgow Coma Scale (GCS) ≤12 points]enrolled between May 2015 and December 2016.There were 45 males and 32 females,with an average age of 36.5 years (range,19-73 years).Among the patients,37 cases were caused by traffic accidents,19 falling from high places,11 falling when walking,and ten by being hit.According to the random number table method,they were divided into control group (39 cases) and treatment group (38 cases).The treatment group received 1 g of tranexamic acid by intravenous injection within ten minutes on the scene and another 1 g of tranexamic acid within eight hours at the hospital.The control group received 0.9％ isotonic saline.The operation and medication followed the routine process.The arrival time of ambulance and the time of first medication use were recorded.The plasma fibrin degradation products (FDP) and D-dimer at admission and 1 d post-trauma,the percentage of cranitomy operation,case fatality rate,red blood cell transfusion,length of stay in the neurosurgical intensive care unit (NICU),and the Glasgow Outcome Scale (GOS) at day 28 were all recorded and analyzed.Results No significant differences were found between the two groups in gender,age,injury causes,GCS,arrival time of ambulance,and the time of first medication use (P ＞ 0.05).The FDP and D-dimer at admission of the two groups were similar (P ＞ 0.05).One day after admission,the expression of plasma FDP was significantly lower in treatment group than that in control group [6758 (4732,13661) μg/L vs.11740 (8516,21756) μg/L] (P ＜ 0.01).The expression of D-dimer was significantly lower in treatment group than that in control group [1074 (849,1414) μg/L vs.1722 (1389,2330) μg/L] (P ＜ 0.01).Between group differences were insignificant in the percentage of craniotomy operation,case fatality rate,and red blood cell transfusion (P ＞ 0.05).However,treatment group showed shorter stay in NICU [4 (1,12)days vs.2 (0,4)days] and higher GOS [4 (3,5)points vs.5 (4,5)points]than control group (both P ＜ 0.01).Conclusions Tranexamic acid can be applied conveniently in pre-hospital emergency care of craniocerebral trauma patients.It can effectively realize the synchronization of pre hospital transport and treatment,eventually reducing the time of NICU treatment as well as improving the prognosis.
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Objectives To research clinical effects of severe brain injury patients treated by acupuncture and herb combine mild hypothermia,discuss the new approach of severe brain injury patients treatment combine Chinese traditional and Western medicine.Methods Investigated 68 severe traumatic brain injured patients,randomly divided into three groups,acupuncture and herb combine mild hypothermia group (n =22),mild hypothermia group (n =24) and normal temperature routine treatment group (n =22).Dynamic intracranial pressure,brain damage index (cytoskeletal protein),immunologic function (IL-6,β2 microglobulin),combine rate of complications (including irritable ulcer,lung infection,epilepsy,sugar metabolism disorder,and so on),and long-term GOS score were analyzed.SPSS12.0 software was used for statistical processing,and the standard deviation of the measurement data were expressed as the standard deviation.The counting data were expressed as apercentage,and the chi-square test was used for the comparison between group.Results There were significant differences between three groups of intracranial pressure,immunologic function,complication occurring rate (P ＜0.05),but there had no significant difference between acupuncture and herb combine mild hypothermia group and mild hypothermia group of brain damage index and GOS,and there have significant difference between these two groups and normal temperature routine treatment group.Conclusions Acupuncture and herb combined mild hypothermia might be better in reducing intracranial pressure,the incidence of complication,and improving immune function of severe brain injury,than mild hypothermia group and normal temperature routine treatment group.
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Objective To compare the clinical effects of neurostimulator positioning nerve block and blind exploration in anesthesia.Methods One hundred and thirty -two patients undergoing upper extremity surgery in the People's Hospital of Xishuangbanna Dai Nationality Autonomous Prefecture were enrolled in this study .According to the digital table,the patients were randomly divided into two groups :blind probing nerve block group ( B group,n＝66) and neurological stimulator locating nerve block group (N group,n＝66).The good rate of anesthesia and compli-cations of the two groups and so on were observed.Results The dosage of anesthetic in B group was (17.6 ± 4.1)mL for anesthesia with 1% lidocaine and 0.375% ropivacaine,which in N group was (18.1 ±4.8)mL,there was no statistically significant difference between the two groups (t＝-0.66,P＞0.05).The good rate of anesthesia in N group was 79.0%,which was higher than that in B group (53.0%),the difference between the two groups was statistically significant(χ2＝9.74,P＜0.05).There were 5 cases(7.6%) turned to general anesthesia because of severe pain in B group,there was no change of anesthesia in N group ,the difference was statistically significant (χ2＝5.20,P＜0.05).The incidence rate of complications in N group was 1.5%,which was lower than 6.1%in B group, the difference was statistically significant (χ2＝4.16,P＜0.05).Conclusion Nerve stimulator has good application value in nerve block anesthesia as a good and cheap tool.
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Prognostication of coma patients after brain injury is important, yet challenging. In this study, we evaluated the predictive value of amplitude-integrated electroencephalography (aEEG) for neurological outcomes in coma patients. From January 2013 to January 2016, 128 coma patients after acute brain injury were prospectively enrolled and monitored with aEEG. The 6-month neurological outcome was evaluated using the Cerebral Performance Category Scale. aEEG monitoring commenced at a median of 7.5 days after coma onset. Continuous normal voltage predicted a good 6-month neurological outcome with a sensitivity of 93.6% and specificity of 85.2%. In contrast, continuous extremely low voltage, burst-suppression, or a flat tracing was correlated with poor 6-month neurological outcome with a sensitivity of 76.5% and specificity of 100%. In conclusion, aEEG is a promising predictor of 6-month neurological outcome for coma patients after acute brain injury.
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Female , Humans , Male , Middle Aged , Brain , Brain Injuries , Diagnosis , Coma , Diagnosis , Electroencephalography , Methods , Follow-Up Studies , Neurophysiological Monitoring , Methods , Prognosis , Prospective Studies , Sensitivity and Specificity , Severity of Illness IndexABSTRACT
Intracranial hypertension remains the key biomarker of severe traumatic brain injury for neurosurgery doctors. The monitoring of intracranial pressure (ICP) provides the technical support of precision and effective treatment strategy. In this article, the authors analyze the methodology, timing, function and development trend of ICP monitoring. The developing process of ICP monitoring contains the efforts of exploring a safe and precise technique to reflect the pressure in an injured brain. The modern ICP monitoring technology provides sufficient information flow for the management of craniocerebral trauma. Neurosurgeons could follow the information in the value and trends of ICP monitoring and implement it into decision making throughout the whole process of patient management. With the advanced data collecting and analyzing system the clinician can look into the waveform and parameter generalized by ICP value, and can interpret to the pathophysiological profiling in brain. ICP monitoring could exert efficacy not only in reflecting the mechanism of brain injury but also in the directing the clinical practice.
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Objective To examine the correlation between end-tidal carbon dioxide (PetCO2) and arterial CO2 (PaCO2) among patients admitted in neurosurgical intensive care unit (NICU) and the factors affecting the PaCO2-PetCO2 [P (a-et) CO2].Methods Thirty-two intubated or cut-trachea patients who presented in the NICU were enrolled.Arterial blood gas test was done at seven every morning,and values of PetCO2 were compared with simultaneously recorded PaCO2.The normal gap of P (a-et) CO2 was defined as-5 mmHg to 5 mmHg.Concordance between PaCO2 and PetCO2 was analyzed using the Bland-Altman plot.Parameters between the normal and high P(a-et) CO2 groups were compared to identify the factors affecting the P(a-et) CO2,including Glasgow Coma Scale(GCS),blood pressure (BP),heart rate (HR),respiration rate (RR),body temperature (BT),and pulse oxygen saturation (SpO2).Results Allvalues of PaCO2 and PetCO2 were in accordance with normal distribution (r =0.668,P ＜ 0.01) and concordance between PaCO2 and PetCO2 was 69.8％.Patients who had high P(aet) CO2 showed lower initial GCS,lower instant GCS,BT,as well as pH and higher actual bicarbonate (AB) and PetCO2 than the patients with normal P (a-et) CO2.Correlation between PaCO2 and PetCO2 rapidly declined when positive end expiratory pressure(PEEP) was greater than 5 mmH2O(r =0.229,P ＜ 0.01).Conclusions PetCO2 correlates well with PaCO2 and appears to be a useful monitor of respiratory function of the patients consecutively.Initial GCS,BT,AB and PEEP have an impact on P(a-et) CO2,so those factors should be considered when attempting to monitor the hyperventilation with PetCO2.
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ObjectiveTo evaluate the clinical benefits of early right median nerve electrical stimulation on coma patients following craniocerebral trauma. MethodsCraniocerebral trauma patients with up to two weeks of coma in the years 2005-2011 were involved in the study and were randomly divided into control group (received routine management ) and treatment group (routine management plus right median nerve electrical stimulation).The treatment lasted for a period of more than two weeks.The clinical efficacy of the right median nerve electric stimulation and the conscious status of the patients within six months after craniocerebral trauma were observed.ResultsA total of 456 patients were enrolled in the study,of whom 437 patients completed the treatment course,including 221 patients in the treatment group and 216 in the control group.There was no complication related to electric stimulation during the treatment.Cerebral blood flow (CBF) imaging and brain stem evoked potential (BEP) examination demonstrated significant improvement in the treatment group.A total of 386 patients were followed up for six months postoperatively,which showed that there were 122 patients with regained consciousness,46 in minimally conscious state and 36 in vegetative state in the treatment group (204 patients) and there were 84 patients with regained consciousness,40 in minimally conscious state and 58 in vegetative state in the control group ( 182 patients).The patients in the treatment group showed a higher ratio of regained consciousness and a lower ratio of vegetative state compared with the control group,but the ratio of minimally conscious state showed no statistical difference between two groups. ConclusionsRight median nerve electrical stimulation is a suitable coma awaking means at early stage after craniocerebral trauma.
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Objective To set up a rat model with acute traumatic coma and identify the variation of microRNA in mesencephalon. Methods After rats were injured moderately by central fluid percussion system, tissues of the mesencephalon were removed one hour after injury. RNA of brain tissue of the mesencephalon was isolated for microRNA array by using the exiqon microarray system. The data were analyzed statistically by Genepix Pro 6.0 after hybridization results were scanned and fluorescence intensity standardized. Resets Hybridization results showed 33 microRNAs with up-regulated expressions but 38 microRNAs with down-regulated activity. Conclusion Expression of microRNA array shows marked changes in the tissues of the mesencephalon in rats with traumatic coma, as may be injury mechanism of traumatic coma and also a way of neurobiological protection of coma.
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Objective To screen the altered gene expression profile of hippocampus after traumatic brain injury(TBI)in rats. Methods Rats(n=3)in experimental group underwent moderate fluid-percussion(F-P)brain injury and the hippoeampus sample in the injured hemisphere was removed and conserved in liquid nitrogen three hours later.The rats(n=5)of the control group underwent the same procedure except for injury.Mfymetrix rat genome 230 2.0 array was used to detect the gene expression profile of hippocampus in two groups and find the altered gene expression profile. Results A total of 159 genes in the experimental group changed significantly(≥2 folds)compared with the control group,of which 136 genes were up-regulated and 23 genes down-regulated. Conclusions The significant gene expression changes of hippocampus,especially a large mount of up-regulated genes,are detected after moderate TBI in rats,suggesting that the secondary injury following TBI is a procedure involving multiple factors.
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Objective To study the early expression of ca]pain Ⅱ and microtubule associated protein 2 (MAP2) mRNA in the hippocampus of the lateral fluid percussion injury rats. Methods 18 Male Sprague-Dawley rats were randomly divided into 3 groups. The changes of Calpaln Ⅱ and MAP2 mRNA in hippocampus 3 h after injury were detected by real-time PCR. Results Compared to the control group (n = 6), the expression for Ca]pain Ⅱ mRNA increased obviously(P <0.01)in the lateral fluid percussion injury group(n=6) ,the expression for MAP2 mRNA degraded obviously(P <0.01). Compared with the lateral fluid percussion injury group(n =6) ,the expression for calpuin Ⅱ mRNA in the mild hypothermia group degraded obviously (n = 6), the expression for MAP2 mRNA increased obviously(P <0.01). Conclusion Mild hypothermia may act as neuroprotection by inhibiting the expression of Ca]pain Ⅱ and easing the degradation of cytoskeleton.
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OBJECTIVE: To investigate the protective effects of mild hypothermia (33-35 degrees C) on the outcome of patients with severe traumatic brain injury (TBI) (GCS<8). METHODS: Patients in the mild hypothermia group were cooled to 33-35 degrees C by cooling blanket with muscular relaxant, and patients in the normothermia group were maintained at 37-38 degrees C. RESULTS: The result showed that the mortality was 26.1% (6/23) in the mild hypothermia group and 58.3% (14/24) in the normothermia group respectively (P<0.05). The mild hypothermia also markedly reduced intracranial pressure (P<0.01 and inhibited hyperglycermia (P<0.05). No significant side-effects were found during hypothermic treatment. CONCLUSIONS: Our clinical data have demonstrated that mild hypothermia is a useful method for management of patients with severe traumatic brain injury.