Prevention of secondary ischemic insults after severe head injury

• Published in: Critical care medicine Vol. 27; no. 10; pp. 2086 - 2095
• Main Authors: Robertson, Claudia S, Valadka, Alex B, Hannay, H Julia, Contant, Charles F, Gopinath, Shankar P, Cormio, Manuela, Uzura, Masahiko, Grossman, Robert G
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins, Inc 01-10-1999; Lippincott
• Subjects: Adolescent; Adult; Analgesics, Opioid - therapeutic use; Biological and medical sciences; Brain Injuries - complications; Brain Injuries - diagnosis; Brain Injuries - drug therapy; Brain Ischemia - diagnosis; Brain Ischemia - etiology; Brain Ischemia - prevention & control; Catheterization, Central Venous; Cerebrovascular Circulation; Critical Care - methods; Diuretics, Osmotic - therapeutic use; Drainage; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Hypnotics and Sedatives - therapeutic use; Injuries of the nervous system and the skull. Diseases due to physical agents; Intracranial Hypertension - diagnosis; Intracranial Hypertension - etiology; Intracranial Hypertension - prevention & control; Intracranial Pressure; Jugular Veins - metabolism; Male; Medical sciences; Oxygen - blood; Tomography, X-Ray Computed; Trauma Centers; Trauma Severity Indices; Traumas. Diseases due to physical agents; Treatment Outcome; Human; Jugular vein; Intensive care; Nervous system diseases; Prognosis; Craniocerebral; Treatment efficiency; Intracranial hypertension; Diseases of the osteoarticular system; Cardiovascular disease; Trauma; Cerebral disorder; Vascular disease; Treatment; Ischemia; Central nervous system disease; Skull disease; Severity score; Cerebrovascular disease; Desaturation; Comparative study; Brain (vertebrata)
• ISSN: 0090-3493; 1530-0293
• DOI: 10.1097/00003246-199910000-00002

OBJECTIVE:The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.
DESIGN:Randomized clinical trial.
SETTING:Level I trauma hospital.
PATIENTS:One hundred eighty-nine adults admitted in coma because of severe head injury.
INTERVENTIONS:Patients were assigned to either cerebral blood flow (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blocks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at > 70 mm Hg and PaCO2 was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2 of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension.
MEASUREMENTS AND MAIN RESULTS:The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p = .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A low jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group. The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome.
CONCLUSIONS:Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.