Management of traumatic brain injury patients / 대한마취과학회지

Traumatic brain injury (TBI) has been called the ‘silent epidemic’ of modern times, and is the leading cause of mortality and morbidity in children and young adults in both developed and developing nations worldwide. In recent years, the treatment of TBI has undergone a paradigm shift. The management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation. The aims and objectives of its management are prophylaxis and prompt management of intracranial hypertension and secondary brain injury, maintenance of cerebral perfusion pressure, and ensuring adequate oxygen delivery to injured brain tissue. In this review, the authors discuss protocol-based approaches to the management of severe TBI as per recent guidelines.

Management of traumatic brain injury patients / 대한마취과학회지

Traumatic brain injury (TBI) has been called the ‘silent epidemic’ of modern times, and is the leading cause of mortality and morbidity in children and young adults in both developed and developing nations worldwide. In recent years, the treatment of TBI has undergone a paradigm shift. The management of severe TBI is ideally based on protocol-based guidelines provided by the Brain Trauma Foundation. The aims and objectives of its management are prophylaxis and prompt management of intracranial hypertension and secondary brain injury, maintenance of cerebral perfusion pressure, and ensuring adequate oxygen delivery to injured brain tissue. In this review, the authors discuss protocol-based approaches to the management of severe TBI as per recent guidelines.

Comparison of intraoperative brain condition, hemodynamics and postoperative recovery between desflurane and sevoflurane in patients undergoing supratentorial craniotomy

Post operative recovery has been reported to be faster with desflurane than sevoflurane anesthesia in previous studies. The use of desflurane is often criticized in neurosurgery due to the concerns of cerebral vasodilation and increase in ICP and studies comparing desflurane and sevoflurane in neurosurgey are scarce. So we compared the intraoperative brain condition, hemodynamics and postoperative recovery in patients undergoing elective supratentorial craniotomy receiving either desflurane or sevoflurane. Fifty three patients between 18-60yr undergoing elective supratentorial craniotomy receiving N[2] O and oxygen [60%:40%] and 0.8-1.2 MAC of either desflurane or sevoflurane were randomized to group S [Sevoflurane] or group D [Desflurane]. Subdural intra cranial pressure [ICP] was measured and brain condition was assessed. Emergence time, tracheal extubation time and recovery time were recorded. Cognitive behavior was evaluated with Short Orientation Memory Concentration Test [SOMCT] and neurological outcome [at the time of discharge] was assessed using Glasgow Outcome Score [GOS] between the two groups. The emergence time [Group D 7.4 +/- 2.7 minutes vs. Group S 7.8 +/- 3.7 minutes; P = 0.65], extubation time [Group D 11.8 +/- 2.8 minutes vs. Group S 12.9 +/- 4.9 minutes; P = 0.28] and recovery time [Group D 16.4 +/- 2.6 minutes vs. Group S 17.1 +/- 4.8 minutes; P = 0.50] were comparable between the two groups. There was no difference in ICP [Group D; 9.1 +/- 4.3 mmHg vs. Group S; 10.9 +/- 4.2 mmHg; P = 0.14] and brain condition between the two groups. Both groups had similar post-operative complications, hospital and ICU stay and GOS. In patients undergoing elective supratentorial craniotomy both sevoflurane and desflurane had similar intra-operative brain condition, hemodynamics and post operative recovery profile

Immediate postoperative complications in transsphenoidal pituitary surgery: a prospective study

Considering the important role of pituitary gland in regulating various endocrine axes and its unique anatomical location, various postoperative complications can be anticipated resulting from surgery on pituitary tumors. We examined and categorized the immediate postoperative complications according to various tumor pathologies. We carried out a prospective study in 152 consecutive patients and noted various postoperative complications during neurosurgical intensive care unit stay [within 48 hrs of hospital stay] in patients undergoing transsphenoidal removal of pituitary tumors. In our series, various groups showed different postoperative complications out of which, cerebrospinal fluid leak was the commonest followed by diabetes insipidus, postoperative nausea and vomiting, and hematoma at operation site. Various immediate postoperative complications can be anticipated in transsphenoidal pituitary surgery even though, it is considered to be relatively safe

Pre-hospital and initial management of head injury patients: an update

Most of the bad outcomes in patients with severe traumatic brain injury [TBI] are related to the presence of a high incidence of pre-hospital secondary brain insults. Therefore, knowledge of these variables and timely management of the disease at the pre-hospital period can significantly improve the outcome and decrease the mortality. The Brain Trauma Foundation guideline on "Prehospital Management" published in 2008 could provide the standardized protocols for the management of patients with TBI; however, this guideline has included the relevant papers up to 2006. A PubMed search for relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic, was conducted. Based on the evidence, majority of the management strategies comprise of rapid correction of hypoxemia and hypotension, the two most important predictors for mortality. However, there is still a need to define the goals for the management of hypotension and inclusion of newer difficult airway carts as well as proper monitoring devices for ensuring better intubation and ventilatory management. Isotonic saline should be used as the first choice for fluid resuscitation. The pre-hospital hypothermia has more adverse effects; therefore, this should be avoided. Most of the management trials published after 2007 have focused mainly on the treatment as well as the prevention strategies for secondary brain injury. The results of these trials would be certainly adopted by new standardized guidelines and therefore may have a substantial impact on the pre-hospital management in patients with TBI

General intensive care for patients with traumatic brain injury: an update

Traumatic brain injury [TBI] is a growing epidemic throughout the world and may present as major global burden in 2020. Some intensive care units throughout the world still have no access to specialized monitoring methods, equipments and other technologies related to intensive care management of these patients; therefore, this review is meant for providing generalized supportive measurement to this subgroup of patients so that evidence based management could minimize or prevent the secondary brain injury. Therefore, we have included the PubMed search for the relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic. General supportive measures are equally important to prevent and minimize the effects of secondary brain injury and therefore, have a substantial impact on the outcome in patients with TBI. The important considerations for general supportive intensive care unit care remain the prompt reorganization and treatment of hypoxemia, hypotension and hypercarbia. Evidences are found to be either against or weak regarding the use of routine hyperventilation therapy, tight control blood sugar regime, use of colloids and late as well as parenteral nutrition therapy in patients with severe TBI. There is also a need to develop some evidence based protocols for the health-care sectors, in which there is still lack of specific management related to monitoring methods, equipments and other technical resources. Optimization of physiological parameters, understanding of basic neurocritical care knowledge as well as incorporation of newer guidelines would certainly improve the outcome of the TBI patients.

Specific intensive care management of patients with traumatic brain injury: present and future

Traumatic brain injury [TBI] is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation [BTF] 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.

Early brain injury and subarachnoid hemorrhage: where are we at present?

The current era has adopted many new innovations in nearly every aspect of management of subarachnoid hemorrhage [SAH]; however, the neurological outcome has still not changed significantly. These major therapeutic advances mainly addressed the two most important sequels of the SAH-vasospasm and re-bleed. Thus, there is a possibility of some different pathophysiological mechanism that would be responsible for causing poor outcome in these patients. In this article, we have tried to compile the current role of this different yet potentially treatable pathophysiological mechanism in post-SAH patients. The main pathophysiological mechanism for the development of early brain injury [EBI] is the apoptotic pathways. The macro-mechanism includes increased intracranial pressure, disruption of the blood-brain barrier, and finally global ischemia. Most of the treatment strategies are still in the experimental phase. Although the role of EBI following SAH is now well established, the treatment modalities for human patients are yet to be testified