Effects of intraoperative lung-protective ventilation on clinical outcomes in patients with traumatic brain injury: a randomized controlled trial

Abstract

Background Secondary lung injury is the most common non-neurological complication after traumatic brain injury (TBI). Lung-protective ventilation (LPV) has been proven to improve perioperative oxygenation and lung compliance in some critical patients. This study aimed to investigate whether intraoperative LPV could improve respiratory function and prevent postoperative complications in emergency TBI patients. Methods Ninety TBI patients were randomly allocated to three groups (1:1:1): Group A, conventional mechanical ventilation [tidal volume (VT) 10 mL/kg only]; Group B, small VT (8 mL/kg) + positive end-expiratory pressure (PEEP) (5 cmH2O); and Group C, small VT (8 mL/kg) + PEEP (5 cmH2O) + recruitment maneuvers (RMs). The primary outcome was the incidence of total postoperative pulmonary complications; Secondary outcomes were intraoperative respiratory mechanics parameters and serum levels of brain injury markers, and the incidence of each postoperative pulmonary and neurological complication. Results Seventy-nine patients completed the final analysis. The intraoperative PaO2 and dynamic pulmonary compliance of Groups B and C were higher than those of Group A (P = 0.028; P = 0.005), while their airway peak pressure and plateau pressure were lower than those of group A (P = 0.004; P = 0.005). Compared to Group A, Groups B and C had decreased 30-day postoperative incidences of total pulmonary complications, hypoxemia, pulmonary infection, and atelectasis (84.0 % vs. 57.1 % vs. 53.8 %, P = 0.047; 52.0 % vs. 14.3 % vs. 19.2 %, P = 0.005; 84.0 % vs. 50.0 % vs. 42.3 %, P = 0.006; 24.0 % vs. 3.6 % vs. 0.0 %, P = 0.004). Moreover, intraoperative hypotension was more frequent in Group C than in Groups A and B (P = 0.007). At the end of surgery, the serum levels of glial fibrillary acidic protein and ubiquitin carboxyl-terminal hydrolase isozyme L1 in Group B were lower than those in Groups A and C (P = 0.002; P < 0.001). The postoperative incidences of neurological complications among the three groups were comparable. Conclusions Continuous intraoperative administration of small VT + PEEP is beneficial to TBI patients. Additional RMs can be performed with caution to prevent disturbances in the stability of cerebral hemodynamics. Trial registration Chinese Clinical Trial Registry (ChiCTR2000038314), retrospectively registered on September 17, 2020.

Effects of positive end-expiratory pressure on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in acute brain injury: Friend or foe? A scoping review

“… Robba et al [ 80 ] Prospective observational study 15 patients with ABI (6 SAH patients, 6 TBI patients, 3 ICH patients) In patients with ABI, C RS , lower MAP, and lung recruitment are associated with ICP rise following incremental levels of PEEP (two levels of PEEP were tested: 5 and 15 cmH 2 O); however, none of those factors was able to predict at baseline the effect of PEEP over ICP. Jiang et al [ 63 ] Randomized controlled trial 90 TBI patients who underwent emergency intracranial hematoma evacuation ONSD (used as ICP change detector method) does not change between patients assisted with traditional MV (V T 10 mL/kg+ 0 cmH 2 O PEEP) and small V T (8 mL/kg) + 5 cmH 2 O PEEP. During a single RM ONSD transiently increased but returned to baseline in 5–10 min, suggesting that RMs could elevate ICP.…”

“…Optic nerve sheath diameter (ONSD) is a bedside non-invasive technique for monitoring changes in ICP. Jiang et al [ 63 ] measured ONSD in TBI patients managed with two different approaches: traditional MV (V T 10 mL/kg + 0 cmH 2 O PEEP) and small V T (8 mL/kg) + 5 cmH 2 O PEEP; no significant differences were seen in ONDS and consequently in the MV approach regarding ICP. During a single recruitment maneuver (RM) (maintain an airway pressure of 30 cmH 2 O for 30 s), the ONSD increased and returned to baseline after 5–10 min.…”

“…[ 88 ] Monitoring: PEEP should always be used under close systemic and multimodal neuromonitoring. Even if invasive ICP remains the gold standard, non-invasive tools like TCD, [ [50] , [51] , [52] , [53] ] ONDS, [ [63] , [64] , [65] ] and LUS [ 75 ] are gaining reliability when invasive ICP is not available. Methods to monitor cerebral oxygenation (NIRS, PtiO 2 , SvjO 2 ) should be implemented in clinical practice.…”

Modelling Amoebic Brain Infection Caused byBalamuthia mandrillarisUsing a Human Cerebral Organoid

“…A meta-analysis reported a significant increase in serum UCH-L1 levels in patients with traumatic brain injury compared to controls [52]. GFAP and UCH-L1 have been used as biomarkers of traumatic brain injury [53]. Studies have reported an increase in blood GFAP levels in neuroinflammation with potential clinical applications [54].…”

Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: a systematic review and meta-analysis

“… 6 , 7 , 9 The calculation of the best PEEP is still a challenge, and several strategies were studied for titrating the best level of PEEP. 10 …”