Acute effects of physiotherapeutic respiratory maneuvers in critically ill patients with craniocerebral trauma

OBJECTIVE: To evaluate the effects of physiotherapeutic respiratory maneuvers on cerebral and cardiovascular hemodynamics and blood gas variables. METHOD: A descriptive, longitudinal, prospective, nonrandomized clinical trial that included 20 critical patients with severe craniocerebral trauma who were receiving mechanical ventilation and who were admitted to the intensive care unit. Each patient was subjected to the physiotherapeutic maneuvers of vibrocompression and increased manual expiratory flow (5 minutes on each hemithorax), along with subsequent airway suctioning with prior instillation of saline solution, hyperinflation and hyperoxygenation. Variables related to cardiovascular and cerebral hemodynamics and blood gas variables were recorded after each vibrocompression, increased manual expiratory flow and airway suctioning maneuver and 10 minutes after the end of airway suctioning. RESULTS: The hemodynamic and blood gas variables were maintained during vibrocompression and increased manual expiratory flow maneuvers; however, there were increases in mean arterial pressure, intracranial pressure, heart rate, pulmonary arterial pressure and pulmonary capillary pressure during airway suctioning. All of the values returned to baseline 10 minutes after the end of airway suctioning. CONCLUSION: Respiratory physiotherapy can be safely performed on patients with severe craniocerebral trauma. Additional caution must be taken when performing airway suctioning because this technique alters cerebral and cardiovascular hemodynamics, even in sedated and paralyzed patients. .

Immunonutrition and cytokine response in patients with head injury.

BACKGROUND: To investigate whether short-term postoperative immunonutrients feeding can modulate the level of cytokines in patients with head injury compared to standard enteral tube feeding formula. MATERIAL AND METHOD: A randomized double-blind study was carried out on 40 moderate to severe head injury patients. They were randomized to have continuous nasogastric tube feeding within 24 hours after surgery of either the immunonutrient containing enteral formula (group A) or the standard enteral formula (group B). The level of interleukin-6 (IL-6) and 10 (IL-10) were measured on day 1 (before feeding), and subsequently on day 3 and day 5. RESULTS: Twenty patients were randomly selected in each group, who had similar severity levels of injury. Compared to the level of IL-6 on day 1, the level of IL-6 was markedly reduced on day 3 in group A (p = 0.002), whereas such reduction in group B was not statistically significant. CONCLUSION: Short term postoperative immunonutrient feeding can reduce cytokine level, indicating that systemic inflammatory response syndrome might be modulated by such feeding.

Measurement of S-100B for risk classification of victims sustaining minor head injury: first pilot study in Brazil

INTRODUÇÃO: A liberação da proteína neuronal S-100B na circulação tem sido sugerida como indicadora de dano neuronal. Foi testada a hipótese de que a S-100B é um marcador útil e custo efetivo para a triagem de pacientes com trauma craniano leve. MÉTODO: Cinqüenta pacientes consecutivos com trauma craniano isolado foram prospectivamente avaliados na sala de emergência de um Centro de Trauma brasileiro pela tomografia computadorizada de crânio e por amostras de sangue venoso, para a medida no soro da proteína S-100B utilizando um teste recentemente desenvolvido; 21 pessoas normais foram utilizadas como controles negativos. Os resultados são apresentados como mediana e percentis 25-75. RESULTADOS: Os pacientes chegaram ao Centro de Trauma em média 45 min (30-62) após o trauma craniano leve. Seis dos 50 pacientes tiveram lesões pós-traumáticas relevantes segundo a tomografia computadorizada de crânio inicial (12%) e foram considerados como positivos. A concentração mediana de S-100B nestes pacientes foi de 0,75µg/L (0,66-6,5), significativamente maior (U-teste, p<0,05) do que a concentração mediana de 0,26µg/L (0.12-0.65) dos pacientes sem lesões pós-traumáticas, segundo a tomografia computadorizada de crânioCCT-. O cálculo para a detecção dos pacientes com lesões intra-cranianas revelou sensibilidade de 100%, especificidade de 20%, valor preditivo positivo de 15% and valor preditivo negativo de 100%. CONCLUSÃO: A proteína S-100B tem altas taxas de sensibilidade e valor preditivo negativo, podendo ter um importante papel para descartar a necessidade de tomografia de crânio após trauma craniano leve. Acreditamos que este achado é de relevância clínica, principalmente em países onde o trauma é muito frequente e os recursos médicos limitados.

Coagulation disorders after head injury

It has become apparent that head trauma triggers abnormalities in numerous body systems, including the haemocoagulative system. Coagulopathy after head trauma is an important aspect from a neurosurgeon's viewpoint. Coagulopathy following head injury may be a relatively more common problem than is appreciated. Various alterations are hypothesized for the occurrence, but the basic abnormality is probably the stimulation of the coagulation system owing to the brain tissue thromboplastins released as a result of brain injury. This may then lead to a brief period of fibrinolysis, and the overall abnormality may flare into a full-fledged disseminated intravascular coagulation [DIC] syndrome. This requires timely evaluation of the Coagulation status, and appropriate corrective measures when present. This is obviously paramount in patients with clinical evidence of DIC, and those requiring urgent neurosurgical interventions. In the remaining, there is debate as to any beneficial effect of treating the abnormal haemostasis. The pathogenesis and the management of this syndrome are discussed in relation to the currently available evidence

Cateterización del bulbo yugular en niños con traumatismo encefálico grave / Yugular bulb blood oxygen saturation in children with severe head trauma

Objetivo: destacar la utilidad de la medición de la saturación de oxígeno en la sangre venosa del bulbo yugular (SatBYO2) en la vigilancia y manejo de la hipoxia o isquemia cerebral global en pacientes con traumatismo encéfalocraneano grave y sus correlaciones con las presiones arterial media, intracraneana y de perfusión cerebral. Pacientes y métodos: once niños (promedio de edades 98 meses, nueve varones), con traumatismo craneoencefálico grave (calificación de Glasgow igual o menor a 8), causado por impacto con vehículos en la vía pública, fueron admitidos a una unidad de cuidados intensivos pediátricos de un hospital suburbano de Santiago durante un período de 12 meses. En todos se introdujo un catéter en el bulbo yugular y se hicieron mediciones de SatBYO2. Resultados: la SatBYO2 era anormalmente baja en cuatro pacientes, en todos había acentuada hiperventilación y en dos hipertensión intracraneana, pero se normalizó mediante ajustes en los controles de los ventiladores mecánicos y el manejo efectivo de la hipertensión intracraneana. No se registraron complicaciones debidas al procedimiento. Todos los pacientes sobrevivieron. Conclusiones: el método es aplicable y seguro en pacientes de unidades pediátricas de cuidados intensivos. La medición de la SatBYO2 es útil como complemento en la evaluación de la oxigenación global cerebral en pacientes con traumatismo encéfalocraneano grave