Mecanismos de lesión cerebral en niños prematuros / Mechanisms of brain injury of the premature baby

Los nacimientos prematuros son uno de los principales indicadores de salud de un país. Están asociados a una alta mortalidad e importante morbilidad en niños con parálisis cerebral y otros trastornos del neurodesarrollo, incluyendo problemas cognitivos y del aprendizaje. Los principales tipos de lesión encefálica en los recién nacidos prematuros son: a) las lesiones de la sustancia blanca, generalmente asociadas a alteraciones neuronales y axonales en la corteza cerebral y otras zonas de sustancia gris; b) hemorragias intracraneanas que incluyen las de la matriz germinal, intraventriculares e intraparenquimatosas y c) del cerebelo. Las lesiones de sustancia blanca incluyen la leucomalacia periventricular quística, no quística (con focos de necrosis microscópicos) y lesiones difusas de sustancia blanca, no necróticas. Estas lesiones tienen múltiples factores etiológicos. Las características anatómicas y fisiológicas de las estructuras vasculares periventriculares predisponen a la sustancia blanca a ser muy vulnerable a las situaciones de isquemia cerebral y, en interacción con factores infecciosos/inflamatorios, activan a las microglías generando estrés oxidativo (por liberación de radicales libres del oxígeno y del nitrógeno), liberación de citoquinas proinflamatorias, liberación de glutamato, fallo energético y alteración de la integridad vascular. Todo lo anteriormente mencionado genera una particular vulnerabilidad de los pre-oligodendrocitos que termina alterando la mielinización. La hipoxia-isquemia también puede producir necrosis neuronal selectiva en diferentes regiones encefálicas. La matriz germinal es un área altamente vascularizada en la región subependimaria periventricular con una estructura capilar muy frágil que la predispone a las hemorragias.

Preterm birth is one of the main country health indicators. It is associated with high mortality and significant morbidity in preterm newborns with cerebral palsy and potential long-term neurodevelopmental disabilities like cognitive and learning problems. The main lesions could be: a) white matter injuries, generally associated with cortical and other regions of grey matter neuronal-axonal disturbances; b) intracranial hemorrhage that includes germinal matrix, intraventricular and parenchymal, c) cerebellum injuries. The white matter lesions include cystic and non-cystic (with microscopic focal necrosis) periventricular leukomalacia and non-necrotic diffuse white matter injury. Multiple etiologic factors are associated with these injuries. Anatomical and physiological characteristics of periventricular vascular structures predispose white matter to cerebral ischemia and, interacting with infection/inflammation factors, activate microglia, generating oxidative stress (mediated by free oxygen and nitrogen radicals), pro-inflammatory cytokine and glutamate toxicity, energetic failure and vascular integrity disturbances. All these factors lead to a particular vulnerability of pre-oligodendrocytes that will affect myelination. Hypoxia-ischemia also may produce selective neuronal necrosis in different cerebral regions. Germinal matrix is a highly vascularized zone beneath ependymal or periventricular region that constitutes a capillary bed with a particular structural fragility that predispose it to hemorrhage.

Serum levels of Selenium and C-reactive protein in comatose patients with severe traumatic brain injury during the first week of hospitalization: case-control study

Introduction: mortality and morbidity related to traumatic brain injuries still remain high in patients. Many authors reported the importance of Selenium in maintaining the integrity of brain functions. This fact is supported by clinical evidence that therapy with selenium supplementation could help patients suffering from brain disorders like neurodegenerative diseases. The aim of our study was to assess the relationship between Selenium concentration in serum and evolution of comatose patients with severe traumatic brain injury, in the first week of admission, and the correlation between selenium and C-reactive protein.Methods: this case-control study was conducted with 64 comatose patients with TBI, in the Department of Anesthesiology and Reanimation, IbnSina University Hospital and Hospital of specialties in Rabat-Morocco, and healthy volunteers recruited in Blood transfusion center of Rabat. Blood sampling was collected from TBI patients, in the first week (3h after admission and each 48h during one week), and from healthy volunteers one time. Concentration of Se in serum was determined by electrochemical atomic absorption spectrometry. Statistical analysis was performed using Statistical software (SPSS) and the cases and controls were compared using the Mann-Whitney U test. A P-value < 0.05 was considered to be statistically significant.Results: comparison selenium concentration in the first day (D0), third day (D2) and fifth day according to the death and survival statue in patients did not show statistical significance (p > 0.05). Selenium concentration of D0 in patients and Selenium concentration in control group also did not show statistical significance (p > 0.05). Similarly, we did not report a correlation between selenium and C-reactive protein.Conclusion: according to our data selenium and CRP may not play a role in progression of coma state in patients with severe traumatic brain injury

Effects of heterologous platelet-rich plasma gel on standardized dermal wound healing in rabbits

PURPOSE: To evaluate the potential of heterologous platelet-rich plasma (PRP) gel for surgical skin wound healing in rabbits METHODS: Blood from a single healthy dog was used for PRP production, with calcium gluconate added to the PRP to form the gel. Two surgical excisions, one to the right and the other to the left of the dorsal midline, were made in six rabbits. One side was randomly allocated to topical application of a physiological solution, and the other was allocated to treatment with heterologous PRP gel. Clinical assessments (weight, pain sensitivity, coloring, edema, hyperemia, exudation, crust, and granulation) and morphometric evaluations were performed 0, 3, 7, 10, 14, and 17 days postoperatively. Histological analysis was performed on the 17th day. RESULTS: With the exception of the presence of a crust at day 10, clinical variables did not differ significantly between the experimental groups. In both the control and PRP-treated groups, differences were identified when comparing time-points in terms of wound area reduction. Histological results indicated no significant differences between the control group and the PRP-treated group. CONCLUSION: Heterologous platelet-rich plasma gel promoted dermal wound healing in rabbits with no adverse effects. .

Sepse em pacientes com traumatismo craniencefálico em unidade de terapia intensiva: fatores relacionados à maior mortalidade / Sepsis in intensive care unit patients with traumatic brain injury: factors associated with higher mortality

Objetivo: Pacientes com traumatismo craniencefálico são particularmente suscetíveis a sepse, a qual pode exacerbar a resposta inflamatória sistêmica e levar à disfunção orgânica. Investigou-se a influência de variáveis clínicas sobre a mortalidade de pacientes com traumatismo craniencefálico e sepse em unidade de terapia intensiva. Métodos: Trata-se de estudo retrospectivo envolvendo 175 pacientes com traumatismo craniencefálico atendidos durante 1 ano em um hospital de referência em trauma, que apresentaram sepse, sepse grave ou choque séptico. Foram obtidos dados demográficos e clínicos e foi aferida a pontuação no escore SOFA no momento da identificação da sepse e após 72 horas. Resultados: Observou-se predomínio de homens jovens, com traumatismo craniencefálico grave, múltiplas lesões cranianas, sepse de foco pulmonar, tempo de internação prolongado e alta mortalidade (37,7%). Falência respiratória e circulatória tiveram alta incidência, já falência renal e da coagulação foram menos frequentes e não se registrou falência hepática. Após a regressão logística, a presença de choque séptico e falência respiratória após 72 horas da identificação da sepse foram associados à maior mortalidade, com odds ratio de 7,56 (IC95%=2,04-27,31; p=0,0024) e 6,62 (IC95%=1,93-22,78; p=0,0027), respectivamente. Ainda, houve maior mortalidade nos pacientes que não possuíam falência orgânica em D1, mas que desenvolveram após 72 horas do diagnóstico de sepse e naqueles que já tinham falência orgânica no momento do diagnóstico da sepse e permaneceram assim após 72 horas. Conclusão: Choque séptico e disfunção orgânica ...

Objective: Patients with traumatic brain injury are particularly susceptible to sepsis, which may exacerbate the systemic inflammatory response and lead to organ dysfunction. The influence of clinical variables on the mortality of intensive care unit patients with traumatic brain injury and sepsis was investigated. Methods: The present investigation was a retrospective study involving 175 patients with traumatic brain injury who were treated in a period of 1 year at a reference hospital for trauma and who had sepsis, severe sepsis, or septic shock. Demographic and clinical data were obtained, and the SOFA score was calculated at the time sepsis was found and after 72 hours. Results: There was a predominance of young men with severe traumatic brain injury, multiple head injuries, sepsis with a pulmonary focus, prolonged hospital stay, and high mortality (37.7%). Circulatory and respiratory failure had a high incidence, but renal and coagulation failure were less frequent, and liver failure was not observed. After logistic regression, the presence of septic shock and respiratory failure 72 hours after the sepsis diagnosis was associated with higher mortality, with an odds ratio of 7.56 (95%CI=2.04-27.31, p=0.0024) and 6.62 (95%CI=1.93-22.78, p=0.0027), respectively. In addition, there was a higher mortality among patients who had no organ failure on D1 but who developed the condition after 72 hours of sepsis and in those patients who already had organ failure at the time sepsis was diagnosed and remained in this condition after 72 hours. Conclusion: Septic shock and progressive organ (particularly respiratory) dysfunction increases the mortality of patients with traumatic brain injury and sepsis. .

Lack of association of S100 and neuron-specific enolase with mortality in critically ill patients

Objective: To evaluate the relationship between brain damage biomarkers and mortality in the intensive care unit (ICU). Methods: The sample comprised 70 patients admitted to an ICU. Blood samples were collected from all patients on ICU admission, and levels of S100β and neuron-specific enolase (NSE) were determined by ELISA. Results: Acute Physiologic and Chronic Health Evaluation (APACHE II) score was associated with mortality, but NSE and S100β were not associated with this outcome. In contrast, S100β levels were significantly higher in delirious and non-delirious patients who required mechanical ventilation during ICU stay. Conclusion: Levels of brain biomarkers at the time of ICU admission did not predict mortality in critically ill patients. .

Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury / A falência da extubação influencia desfechos clínicos e funcionais em pacientes com traumatismo cranioencefálico

OBJECTIVE: To evaluate the association between extubation failure and outcomes (clinical and functional) in patients with traumatic brain injury (TBI). METHODS: A prospective cohort study involving 311 consecutive patients with TBI. The patients were divided into two groups according to extubation outcome: extubation success; and extubation failure (defined as reintubation within 48 h after extubation). A multivariate model was developed in order to determine whether extubation failure was an independent predictor of in-hospital mortality. RESULTS: The mean age was 35.7 ± 13.8 years. Males accounted for 92.3%. The incidence of extubation failure was 13.8%. In-hospital mortality was 4.5% and 20.9% in successfully extubated patients and in those with extubation failure, respectively (p = 0.001). Tracheostomy was more common in the extubation failure group (55.8% vs. 1.9%; p < 0.001). The median length of hospital stay was significantly greater in the extubation failure group than in the extubation success group (44 days vs. 27 days; p = 0.002). Functional status at discharge was worse among the patients in the extubation failure group. The multivariate analysis showed that extubation failure was an independent predictor of in-hospital mortality (OR = 4.96; 95% CI, 1.86-13.22). CONCLUSIONS: In patients with TBI, extubation failure appears to lengthen hospital stays; to increase the frequency of tracheostomy and of pulmonary complications; to worsen functional outcomes; and to increase mortality. .

OBJETIVO: Avaliar a associação entre falência da extubação e desfechos clínicos e funcionais em pacientes com traumatismo cranioencefálico (TCE). MÉTODOS: Coorte prospectiva com 311 pacientes consecutivos com TCE. Os pacientes foram divididos em dois grupos de acordo com o resultado da extubação: sucesso ou falência (necessidade de reintubação dentro de 48 h após extubação). Um modelo multivariado foi desenvolvido para verificar se a falência de extubação era um preditor independente de mortalidade hospitalar. RESULTADOS: A média de idade foi de 35,7 ± 13,8 anos, e 92,3% dos pacientes eram do sexo masculino. A incidência de falência da extubação foi de 13,8%. A mortalidade hospitalar foi, respectivamente, de 20,9% e 4,5% nos pacientes com falência e com sucesso da extubação (p = 0,001). A realização de traqueostomia foi mais frequente no grupo falência da extubação (55,8% vs. 1,9%; p < 0,001). A mediana de tempo de permanência hospitalar foi significantemente maior nos pacientes com falência do que naqueles com sucesso da extubação (44 dias vs. 27 dias; p = 0,002). Os pacientes com falência da extubação apresentaram piores desfechos funcionais na alta hospitalar. A análise multivariada mostrou que a falência da extubação foi um preditor independente para a mortalidade hospitalar (OR = 4,96; IC95%, 1,86-13,22). CONCLUSÕES: A falência da extubação esteve associada a maior permanência hospitalar, maior frequência de traqueostomia e de complicações pulmonares, piores desfechos funcionais e maior mortalidade em pacientes com TCE. .

Analysis of cranio-cerebral injuries by blunt force.

Despite current advances in public education and in automobile safety requirements, cranio-cerebral injuries continues to be a major cause of morbidity and mortality and accounts for significant portion of health care costs today. Trauma respects neither geography nor body systems. Consequently head injury occurs every 15 seconds and a patient dies from a head injury every 12 minutes, a day doesn’t pass that an emergency department physician is not confronted with a head injured patient. The present work is based on the observation and study made on 117 cases collected. These cases include 39 cases who died before being admitted to any hospital and were sent directly by the police to postmortem, Mysore Medical College, Mysore, and 78 cases that died in the hospital under medical care. Clinical data are available for 78 cases that died in the hospital after undergoing some treatment. An attempt is made in these cases to correlate clinical findings with the autopsy findings.

Effect of posttraumatic serum thyroid hormone levels on severity and mortality of patients with severe traumatic brain injury

Traumatic brain injury [TBI] is an important cause of death and disability in young adults ,and may lead to physical disabilities and long-term cognitive, behavioral psychological and social defects. There is a lack of definite result about the effect of thyroid hormones after traumatic brain injury in the severity and no data about their effect on mortality of the injury. The aim of this study is to evaluate the effect of thyroid hormones after traumatic brain injury in the severity and mortality and gain a clue in brain injury prognosis. In a longitudinal prospective study from February 2010 until February 2011, we checked serum levels of T3, T4, TSH and TBG of severely brain injured patients and compared the relationship of them with primary Glasgow Coma Scale [GCS] score and mortality of patients. Statistical analysis used SPSS 11.5 software with using chi-square and Fisher exact test. Serum levels of T3 and T4 were decreased after brain trauma but not TSH and TBG. Mortality rates were higher in patients with lower T4 serum levels. The head injury was more severe in whom with low T3 and T4. Follow a severe brain injury a secondary hypothyroidism is happened due to pituitary dysfunction. Also, serum level of T3 and T4 on the first day admission affect on primary GCS score of patients which is an indicator of severity of brain injury. In addition, mortality rates of severely brain injured patients have a high correlation with the serum level of T4 in the first day admission

In-hospital mortality and the Glasgow Coma Scale in the first 72 hours after traumatic brain injury / Escala de Coma de Glasgow nas primeiras 72 horas após trauma cranioencefálico e mortalidade hospitalar / Escala de Coma de Glasgow en las primeras 72 horas postrauma encefalocraneano y mortalidad hospitalaria

This study verifies and compares the performance of three different scores obtained in the Glasgow Coma Scale (GCS) in the first 72 hours post trauma in predicting in-hospital mortality. The studied scores included those obtained after initial care was provided at the hospital, and the worst and best scores obtained in the scale in the first 72 hours post trauma. The scale’s predictive ability was assessed by the Receiver Operator Characteristic (ROC) curve. A total of 277 victims with different severity levels of blunt traumatic brain injuries were studied. The performance of the three scores that were analyzed to predict hospital mortality was moderate (0.74 to 0.79) and the areas under the curve did not present statistically significant differences. These findings suggest that any of the three studied scores can be applied in clinical practice to estimate the outcome of victims with blunt traumatic brain injuries, taking into consideration the instrument’s moderate discriminatory power.

O estudo teve como objetivos verificar e comparar o desempenho de escores da Escala de Coma de Glasgow (ECGl) observados nas primeiras 72 horas após trauma, para predizer mortalidade hospitalar. Os valores analisados foram os escores obtidos após atendimento inicial intra-hospitalar, além dos piores e melhores resultados da escala nas primeiras 72 horas pós-trauma. A capacidade preditiva dos escores da ECGl para estado vital à saída hospitalar foi avaliada, utilizando-se a curva Reciever Operator Characteristic. Foram estudadas 277 vítimas, com trauma cranioencefálico contuso de diferentes gravidades. O desempenho dos escores da ECGl para estado vital à saída hospitalar foi moderado (0,74 a 0,79) e as áreas sob a curva não apresentaram diferença significativa. Os resultados sugerem que qualquer um dos três valores da ECGl analisados podem ser aplicados na prática clínica para estimar o prognóstico das vitimas de trauma cranioencefálico contuso, considerando-se, no entanto, seu moderado poder discriminatório.

El estudio tiene como objetivos verificar y comparar el desempeño de puntajes de la Escala de Coma de Glasgow (ECGl) observados en las primeras 72 horas postrauma para predecir la mortalidad hospitalaria. Los valores analizados fueron los puntajes obtenidos después de la atención inicial intra-hospitalaria, además de los peores y mejores resultados de la escala en las primeras 72 horas postrauma. La capacidad de predicción de los puntajes de la ECGl para el Estado Vital a la Salida Hospitalaria fue evaluada, utilizando la curva Reciever Operator Characteristic. Fueron estudiadas 277 víctimas, con trauma encefalocraneano contuso de diferentes gravedades. El desempeño de los puntajes de la ECGl para el estado vital a la salida hospitalaria fue moderado (0,74 a 0,79) y las áreas bajo la curva no presentaron diferencia significativa. Los resultados sugieren que cualquiera de los tres valores de la ECGl analizados pueden ser aplicados en la práctica clínica para estimar el pronóstico de las víctimas de trauma encefalocraneano contuso, considerando, sin embargo su moderado poder discriminatorio.

Hiperglicemia na admissão é um preditor confiável da evolução de crianças com traumatismo cerebral grave / Admission hyperglycemia is a reliable outcome predictor in children with severe traumatic brain injury

OBJETIVO: Identificar a relação entre hiperglicemia na admissão e desfecho das crianças com traumatismo cerebral grave na alta hospitalar e 6 meses depois. MÉTODO: Análise retrospectiva da glicemia de 61 crianças com traumatismo cerebral grave admitidas na unidade de tratamento intensivo pediátrico entre 1/11/2005 e 30/10/2009. Foi considerado um ponto de corte de > 150 mg/dL para o diagnóstico da hiperglicemia, com base na literatura. A evolução foi avaliada pela escala de resultados de Glasgow na alta hospitalar e 6 meses após a alta. O óbito também foi analisado como uma evolução. RESULTADOS: A glicemia média dos pacientes na admissão foi de 251 mg/dL (68-791). Verificou-se hiperglicemia na admissão em 51 pacientes (83,6 por cento). Encontrou-se uma correlação positiva moderadamente significativa entre glicemia na admissão e gravidade do traumatismo craniano segundo a escala abreviada de injúrias (r = 0,46). A glicemia média dos não sobreviventes foi significativamente maior (207 mg/dL versus 455 mg/dL, p < 0,001). A glicemia média dos pacientes com má evolução foi significativamente maior, comparada à daqueles com boa evolução, na alta hospitalar e 6 meses após a alta (185 mg/dL versus 262 mg/dL, p < 0,15 e 184 mg/dL versus 346 mg/dL, p < 0,04, respectivamente). CONCLUSÕES: A hiperglicemia pode ser considerada um marcador de lesão cerebral e, quando presente na admissão, pode refletir um dano cerebral extenso, frequentemente associado a desfecho negativo e mortalidade. São necessários mais estudos para investigar o efeito do controle rigoroso da glicemia sobre a mortalidade e a evolução.

OBJECTIVE: To identify the relationship between admission hyperglycemia and outcome in children with severe brain injury at hospital discharge and 6 months later. METHOD: A retrospective analysis of blood glucose levels was conducted in 61 children with severe brain injury admitted to the Pediatric Intensive Care Unit between November 1, 2005 and October 30, 2009. Hyperglycemia was considered for a cut off value of > 150 mg/dL, based on literature. Outcome was measured with the Glasgow Outcome Scale at hospital discharge and 6 months after discharge. Death was also analyzed as an outcome measure. RESULTS: Mean admission blood glucose of the patients was 251 mg/dL (68-791). Hyperglycemia was noted on admission in 51 (83.6 percent) patients. A moderately significant positive correlation was found between admission blood glucose and severity of head trauma according to Abbreviated Injury Score (r = 0.46). Mean admission glucose level of non-survivors was significantly higher (207 mg/dL vs. 455 mg/dL, p < 0.001). Mean blood glucose level of the patients in bad outcome group was found significantly higher compared to that of the patients in good outcome group at hospital discharge and 6 months after discharge (185 mg/dL vs. 262 mg/dL, p < 0.15 and 184 mg/dL vs. 346 mg/dL, p < 0.04, respectively). CONCLUSIONS: Hyperglycemia could be considered as a marker of brain injury and, when present upon admission, could reflect extensive brain damage, frequently associated with mortality and bad outcome. Further studies are needed to investigate the effect of strict glycemic control on mortality and outcomes.

Intensive insulin therapy versus conventional glycemic control in patients with acute neurological injury: a prospective controlled trial

OBJECTIVE: To compare intensive insulin therapy to conventional glycemic control in patients with acute neurological injury evaluating neurological outcome and morbimortality. METHOD: Patients with two glycemias above 150 mg/dL 12 hours after admission were randomized to receive intensive insulin therapy (G1) or conventional treatment (G2). We evaluated a subgroup of patients with acute brain injury from July, 2004 to June, 2006. RESULTS: G1 patients (n=31) received 70.5 (45.1-87.5) units of insulin/day while G2 patients (n=19) received 2 (0.6-14.1) units/day (p<0.0001). The median glycemia was comparable in both groups (p=0.16). Hypoglycemia occurred in 2 patients (6.4 percent) in G1 and in 1 patient (5.8 percent) in G2 (p=1.0). Mortality in G1 was of 25.8 percent and of 35.2 percent in G2 (relative reduction of 27 percent). Neurological outcome was similar in both groups. CONCLUSION: A less strict intensive insulin therapy can reduce hypoglycemia and still maintain its benefits.

OBJETIVO: Comparar insulinoterapia intensiva com controle convencional da glicemia em pacientes com injuria cerebral aguda avaliando evolução neurológica e morbimortalidade. MÉTODO: Pacientes com duas glicemias acima de 150 mg/dL nas primeiras 12 horas após admissão foram randomizados para insulinoterapia intensiva (Grupo 1) ou tratamento convencional (Grupo 2). Avaliamos um subgrupo de pacientes com injuria cerebral aguda admitidos de julho/2004 a junho/2006. RESULTADOS: O Grupo 1 (n=31) recebeu 70,5 (45,1-87,5) unidades de insulina/dia enquanto o Grupo 2 (n=19) recebeu 2 (0,6-14,1) unidades/dia (p<0,0001). A glicemia mediana foi comparável nos dois grupos (p=0,16). Hipoglicemia ocorreu em 2 pacientes (6,4 por cento) no Grupo 1 e em 1 paciente (5,8 por cento) no Grupo 2. A mortalidade no Grupo 1 foi 25,8 por cento contra 35,2 por cento no Grupo 2 (redução relativa de 27 por cento). A evolução neurológica foi semelhante nos dois grupos. CONCLUSÃO: Insulinoterapia intensiva com controle mais flexível da glicemia reduz a incidência de hipoglicemia mantendo os benefícios do tratamento.

Distúrbio de coagulação em crianças e adolescentes com traumatismo cranioencefálico moderado e grave / Coagulation disorder in children and adolescents with moderate to severe traumatic brain injury

OBJETIVOS: Descrever o perfil epidemiológico de crianças e adolescentes com traumatismo cranioencefálico moderado e grave internados em unidade de tratamento intensivo; descrever a freqüência de alterações na coagulação destes pacientes; determinar a relação entre a coagulopatia e a gravidade do trauma; analisar os fatores associados à coagulopatia; e verificar a influência da coagulopatia na mortalidade desses pacientes. MÉTODOS: Estudo transversal com 301 pacientes de até 16 anos internados em terapia intensiva devido a traumatismo cranioencefálico moderado e grave, compreendendo período de 5 anos. O perfil de coagulação foi associado com achados clínicos, epidemiológicos e tomográficos. Análises univariada e multivariada foram empregadas para verificar a associação entre presença de coagulopatia e mortalidade. RESULTADOS: A idade mínima foi de 23 dias, e a máxima, de 16 anos (média de 7,9 anos). Cerca de 77 por cento dos pacientes apresentaram coagulopatia, cuja ocorrência esteve diretamente associada à gravidade do trauma, mas não ao aumento da mortalidade. Os fatores associados com a presença de coagulopatia foram: gravidade do traumatismo cranioencefálico (OR = 2,83; IC95 por cento 1,58-5,07), diagnóstico de edema e ingurgitamento cerebral à tomografia computadorizada de crânio (OR = 2,11; IC95 por cento 1,13-4,07) e ocorrência de trauma torácico e/ou abdominal (OR = 2,07; IC95 por cento 1,11-4,00). Aproximadamente 35 por cento dos pacientes morreram. Em análise multivariada, os fatores que se relacionaram ao aumento do risco de morrer foram: ocorrência de distúrbios de sódio (OR = 5,56; IC95 por cento 2,90-10,65), hipotensão no centro de tratamento intensivo (OR = 12,58; IC95 por cento 4,40-35,00) e síndrome do desconforto respiratório agudo (OR = 13,57; IC95 por cento 1,51-121,66). CONCLUSÃO: O surgimento de coagulopatia é uma complicação freqüente nos pacientes vítimas de traumatismo cranioencefálico moderado e grave. Apesar...

OBJECTIVES: To describe the epidemiological profile of children and adolescents with moderate to severe traumatic brain injury admitted to an intensive care unit; to describe the frequency of coagulation disorders in these patients; to determine the relationship between coagulopathy and trauma severity; to assess the factors associated with coagulopathy; and to assess the effect of coagulopathy on the mortality of these patients. METHODS: Cross-sectional study with 301 patients aged up to 16 years admitted to an intensive care unit due to moderate to severe traumatic brain injury, carried out over a 5-year period. The coagulation profile was associated with clinical, epidemiological and CT findings. Univariate and multivariate analyses were used to check the association between coagulopathy and mortality. RESULTS: Minimum age was 23 days, and maximum age was 16 years (mean of 7.9 years). About 77 percent of patients had coagulopathy, whose occurrence was directly associated with the severity of the trauma, but not with the rise in mortality. The factors associated with the presence of coagulopathy were the following: severity of the traumatic brain injury (OR = 2.83; 95 percentCI 1.58-5.07), diagnosis of brain swelling on cranial computed tomography (OR = 2.11; 95 percentCI 1.13-4.07) and occurrence of chest and/or abdominal injury (OR = 2.07; 95 percentCI 1.11-4.00). Approximately 35 percent of patients died. The multivariate analysis showed that the factors associated with an increased risk of death were presence of sodium disorders (OR = 5.56; 95 percentCI 2.90-10.65), hypotension in the intensive care unit (OR = 12.58; 95 percentCI 4.40-35.00) and acute respiratory distress syndrome (OR = 13.57; 95 percentCI 1.51-121.66). CONCLUSION:The development of coagulopathy is a frequent complication in patients with moderate to severe traumatic brain injury. Even though it is not closely associated with death in this study, it may be regarded...

Traumatic brain injury in pediatric age group; Predictors of outcome in pediatric intensive care unit

To determine predictors for outcomes of traumatic brain injury [TBI] in infants and children younger than twelve years admitted to our pediatric intensive care units [PICU]. This is a retrospective cohort study from 2004-5, done at the PICU of King Fahad Hofuf Hospital, Eastern Province, Saudi Arabia. One hundred and six patients with TBI; 65 boys and 41 girls ages 12 or under, with a mean age of 5.7 years, were included. Of them, 11.3% died [Deaths group], 11% survived with neurological deficits [NDgroup], and 77% survived with no neurological deficits [NND-group]. The potential predictors for death or neurological deficits were examined. 83% of deaths had initial Glascow coma scale [GCS] of

Outcome prediction model for severe diffuse brain injuries: development and evaluation.

BACKGROUND: Intensive care resources for the management of severe diffuse brain injury patients (SDBI) are limited. Their optimal use is possible only if we can predict at admission which patients are unlikely to improve. AIMS: To develop a simple and effective model to predict poor outcome in patients with SDBI in order to help guide initial therapy. MATERIAL AND METHODS: The prognostic factors and outcomes of 289 patients with severe diffuse brain injury (GCS 3-8) were analyzed retrospectively. The prognostic factors analyzed were age, mode of injury, GCS at admission, pupillary reaction, horizontal oculocephalic reflex, and CT scan findings. Outcome at 1 month was classified as unfavorable--death or persistent vegetative state, or favorable--improvement with or without some disability. A stepwise linear logistic regression analysis was used to identify the most important predictors of poor outcome. A prediction model (NIMHANS model-NM) was developed using these factors. NM and several currently available outcome prediction models were prospectively applied in a separate group of 26 patients with severe diffuse brain injury managed with a different protocol. RESULTS: The most important predictors of poor outcome were found to be the horizontal oculocephalic reflex, motor score of GCS, and midline shift on CT scan. NM was found to be more sensitive (75%) and specific (67%) than most other models in predicting unfavorable outcome. NM had high false pessimistic results (33%). CONCLUSION: Prediction models cannot be used to guide initial therapy.

Caracterización de la mortalidad en la unidad de cuidados intensivos: año 1998 / Characterization of mortality in intensive care units in 1998

Se realizó un estudio descriptivo retrospectivo de los pacientes fallecidos en el año 1998, para caracterizar la mortalidad en la Unidad de Cuidados Intensivos del Hospital Universitario ®Dr. Gustavo Aldereguía Lima¼ de Cienfuegos. Se obtuvieron los datos necesarios del informe mensual emitido por el Comité de Análisis de la Mortalidad Hospitalaria. Se observó que la edad media de los fallecidos fue de 52,50 ñ 21,28 años, que procedían en su mayoría del servicio de urgencias (49 porciento) y del salón de operaciones (25,5 porciento) y que predominaron los ingresos médicos sobre los quirúrgicos. El promedio de estadía fue de 6,53 ñ 9,82 d. Se halló como la principal causa de muerte el infarto miocárdico agudo (27,6 porciento) seguido del traumatismo (18,32 porciento). Existió concordancia clínicopatológica total en el 71,6 porciento de los fallecidos. Se comprobó que la letalidad de los fallecidos con infarto miocárdico agudo trombolizado fue del 8 porciento y la de los no trombolizados, del 26 porciento, mientras que la de traumatismo de cráneo con traumatismo múltiple o sin este fue de 62,5 porciento y de 8,5 porciento la de traumatismo múltiple sin traumatismo de cráneo

Traumatismo cranioencefálico: biomecânica, avaliaçäo e manejo / Craniocerebral trauma: biomechanics, evaluatin and management

Os traumatismos cranioencefálicos representam importante causa de mortalidade e morbidade na sociedade contemporânea. Embora o trauma craniano possa variar em muito potencial, visto que os eventos fisiopatogênicos envolvidos sao extremamente dinâmicos e complexos. O traumatismo craniano apresenta-se freqüentemente associado com lesao em outros sistemas orgânicos: fraturas de ossos longos, traumatismo de tórax e abdômen, sobretudo nos acidentes automobilísticos ou nos atropelamentos de pedestres. Antigamente a preocupaçao dos insultos secundários ao cérebro, como o choque hipovolêmico ou neurogênico e a hipóxia, estavam voltados somente para os pacientes com trauma craniano severo associado a alteraçoes sistêmicas importantes. Evidências atuais indicam que níveis moderados de hipotensao arterial e hipóxia, sao suficientes para converter uma lesao cerebral reversível em irreversível. Assim sendo, a correçao da hipóxia e a normalizaçao imediata da pressao sanguínea sao medidas essenciais nesses pacientes. Concomitantemente, deve haver uma avaliaçao cautelosa das lesoes externas, exame neurológico completo e solicitaçao de exames radiológicos e laboratoriais para verificar a situaçao de cada paciente, com vistas à adoçao de uma conduta apropriada.

Estudo prospectivo de 200 casos de TCE grave na grande Florianópolis / A prospective study of two hundred of severe brain injuries in Florianópolis - Brazil

Foi realizado estudo de 200 casos consecutivos de traumas de crânios severos, internados na Unidade de Terapia Intensiva do Hsopital Governador Celso Ramos que é referência da área de neurotraumatologia na grande Florianópolis de populaçäo estimada de 500 mil habitantes; após coleta em um banco de dados no período de novembro de 1993 a abril de 1996, foi correlacionado dados de epidemiologia, diagnóstico intracraniano, complicaçöes clínicas, traumas associados a mortalidade global e específica e comparado com os estudos da literatura estrangeira.