Impact of Cervical Collars on Intracranial Pressure Values in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prospective Studies.

BACKGROUND: Spinal cord injury (SCI) is present in around 2-4% of trauma victims. More than half of this injuries are located at the cervical region. Twenty percent of victims with cervical spinal trauma and 5% of patients with severe traumatic brain injury (TBI) will have an SCI. Cervical immobilization with rigid or semirigid collars is routinely used as prophylactic or definitive treatment intervention in general trauma care. An important adverse effect of cervical collars application is the increase in intracranial pressure (ICP) values. This systematic review and meta-analysis aim to estimate the overall magnitude of ICP changes after cervical collar application. METHODS: Major electronic databases (Ovid/Medline, Embase and Cochrane Library) were systematically searched for prospective studies that assessed ICP changes after cervical collar applications. Study level characteristics and ICP values before, during and after cervical collar application, were extracted. The meta-analysis was performed using random-effects model. RESULTS: Five studies comprising 86 patients were included in the systematic review and the quantitative synthesis. The overall increase in ICP after collar application was statistically significant (weighted mean difference [WMD] = 4.43; 95%CI 1.70, 7.17; P < 0.01), meaning an overall ICP increase of approximately 4.4 mmHg. The decrease in ICP values after collar removal reached statistical significance (WMD = - 2.99; 95%CI - 5.45, - 0.52; P = 0.02), meaning an overall ICP decrease of approximately 3 mmHg after collar removal. ICP values before and after cervical collar application were not statistically significant (WMD = 0.49; 95%CI - 1.61, 2.59; P = 0.65), meaning no ICP change. CONCLUSIONS: Heterogeneous studies of application of cervical collars as a partial motion restriction strategy after injuries have demonstrated increases in ICP in TBI patients. Increases in ICP can induce complications in TBI patients. Appropriate selection criteria for cervical motion restriction in TBI patients need to be considered.

Intracranial Hypertension After Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Prevalence and Mortality Rate.

The objective of this study was to determine the prevalence of intracranial hypertension (IHT) and the associated mortality rate in patients who suffered from primary intracerebral hemorrhage (ICH). A secondary objective was to assess predisposing factors to IHT development. We conducted a systematic literature search of major electronic databases (MEDLINE, EMBASE, and Cochrane Library), for studies that assessed intracranial pressure (ICP) monitoring in patients with acute ICH. Study level and outcome measures were extracted. The meta-analysis was performed using a random-effects model. A total of six studies comprising 381 patients were pooled to estimate the overall prevalence of any episode of IHT (ICP > 20 mmHg) after ICH. The pooled prevalence rate for any episode of IHT after ICH was 67% (95% CI 51-84%). Four studies comprising 239 patients were pooled in order to estimate the overall mortality rate associated with IHT. Pooled mortality rate was 50% (95% CI 24-76%). For both outcomes, heterogeneity was statistically significant, and risk of bias was nonsignificant. Reported variables correlated significantly with increased ICP were lower Glasgow Coma Scale score at admission, midline shift, hemorrhage volume, and hydrocephalus. The prevalence and mortality rates associated with IHT after ICH are high and may be underestimated. Predicting factors for the development of IHT reflect the magnitude of the primary injury. However, the results of present meta-analysis should be interpreted with caution due to methodological limitations such as selection bias of patients who had ICP monitoring, and lack of standardized IHT definition.

Comparison of intensive versus conventional insulin therapy in traumatic brain injury: a meta-analysis of randomized controlled trials.

OBJECTIVE: To compare intensive insulin therapy (IIT) and conventional insulin therapy (CIT) on clinical outcomes of patients with traumatic brain injury (TBI). METHODS: MEDLINE, EMBASE, Google Scholar, ISI Web of Science, and Cochrane Library were systematically searched for randomized controlled trials (RCTs) comparing IIT to CIT in patients with TBI. Study-level characteristics, intensive care unit (ICU) events, and long-term functional outcomes were extracted from the articles. Meta-analysis was performed with random-effect models. RESULTS: Seven RCTs comprising 1070 patients were included. Although IIT was associated with better neurologic outcome (GOS > 3) (RR=0.87, 95% CI=0.78-0.97; P=0.01; I2=0%), sensitivity analysis revealed that one study influenced this overall estimate (RR=0.90, 95% CI=0.80-1.01, P=0.07; I2=0%). IIT was strongly associated with higher risk of hypoglycaemia (RR=5.79, 95% CI=3.27-10.26, P<0.01; I2=38%). IIT and CIT did not differ in terms of early or late mortality (RR=0.96, 95% CI=0.79-1.17, P=0.7; I2=0%), infection rate (RR=0.82, 95% CI=0.59-1.14, P=0.23; I2=68%), or ICU length of stay (SMD= -0.14, 95% CI=-0.35 to 0.07, P=0.18; I2=45%0.) Conclusions: IIT did not improve long-term neurologic outcome, mortality, or infection rate and was associated with increased risk of hypoglycaemia. Additional well-designed RCTs with defined TBI subgroups should be performed to generate more powerful conclusions.

The Impact of Volatile Anesthetic Choice on Postoperative Outcomes of Cardiac Surgery: A Meta-Analysis.

OBJECTIVES: To evaluate the impact of volatile anesthetic choice on clinically relevant outcomes of patients undergoing cardiac surgery. METHODS: Major databases were systematically searched for randomized controlled trials (RCTs) comparing volatile anesthetics (isoflurane versus sevoflurane) in cardiac surgery. Study-level characteristics, intraoperative events, and postoperative outcomes were extracted from the articles. RESULTS: Sixteen RCTs involving 961 patients were included in this meta-analysis. There were no significant differences between both anesthetics in terms of intensive care unit length of stay (SMD -0.07, 95% CI -0.38 to 0.24, P = 0.66), hospital length of stay (SMD 0.06, 95% CI -0.33 to 0.45, P = 0.76), time to extubation (SMD 0.29, 95% CI -0.08 to 0.65, P = 0.12), S100ß (at the end of surgery: SMD 0.08, 95% CI -0.33 to 0.49, P = 0.71; 24 hours after surgery: SMD 0.21, 95% CI -0.23 to 0.65, P = 0.34), or troponin (at the end of surgery: SMD -1.13, 95% CI -2.39 to 0.13, P = 0.08; 24 hours after surgery: SMD 0.74, 95% CI -0.15 to 1.62, P = 0.10). CK-MB was shown to be significantly increased when using isoflurane instead of sevoflurane (SMD 2.16, 95% CI 0.57 to 3.74, P = 0.008). CONCLUSIONS: The volatile anesthetic choice has no significant impact on postoperative outcomes of patients undergoing cardiac surgery.