Hyperventilation in Severe Traumatic Brain Injury Has Something Changed in the Last Decade or Uncertainty Continues? A Brief Review

Godoy, Daniel Agustín; Badenes, Rafael; Robba, Chiara; Cabezas, F. Murillo

doi:10.3389/fneur.2021.573237

Cited by 7 publications

(3 citation statements)

References 29 publications

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“…Almost one-third of the cohort had an arrival ETCO 2 <30 mm Hg. While prolonged hypocapnia is associated with poorer outcomes 3 6 10 due to cerebral vasoconstriction and potential ischaemic injury, 29 we did not find any independent mortality effect from an arrival ETCO 2 <30 mm Hg. In our study, 43.8% of the hypocapnic patients also received HTS implying that hyperventilation may have been used as an additional temporising measure to reduce intracranial pressure.…”

Section: Discussioncontrasting

confidence: 73%

Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study

et al. 2023

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BackgroundPrehospital neuroprotective strategies aim to prevent secondary insults (SIs) in traumatic brain injury (TBI). This includes haemodynamic optimisation in addition to oxygenation and ventilation targets achieved through rapid sequence intubation (RSI).The primary aim was to report the incidence and prevalence of SIs (prolonged hypotension, prolonged hypoxia and hyperventilation) and outcomes of patients with TBI who were intubated in the prehospital setting.MethodsA retrospective cohort study of adult patients with TBI who underwent RSI by a metropolitan road-based service in South-East Queensland, Australia between 1 January 2017 and 31 December 2020. Patients were divided into two cohorts based on the presence or absence of any SI sustained. Prolonged SIs were defined as occurring for ≥5 min. The association between SIs and mortality was examined in multivariable logistic regression and reported with adjusted ORs (aORs) and 95% CIs.Results277 patients were included for analysis. Median ‘Head’ Abbreviated Injury Scale and Injury Severity Score were 4 (IQR: 3–5) and 26 (IQR: 17–34), respectively. Most episodes of prolonged hypotension and prolonged hypoxia were detected with the first patient contact on scene. Overall, 28-day mortality was 26%. Patients who sustained any SI had a higher mortality than those sustaining no SI (34.9% vs 14.7%, p<0.001). Prolonged hypoxia was an independent predictor of mortality (aOR 4.86 (95% CI 1.65 to 15.61)) but not prolonged hypotension (aOR 1.45 (95% CI 0.5 to 4.25)) or an end-tidal carbon dioxide <30 mm Hg on hospital arrival (aOR 1.28 (95% CI 0.5 to 3.21)).ConclusionSIs were common in the early phase of prehospital care. The association of prolonged hypoxia and mortality in TBI is potentially more significant than previously recognised, and if corrected early, may improve outcomes. There may be a greater role for bystander intervention in prevention of early hypoxic insult in TBI.

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Section: Discussioncontrasting

confidence: 73%

Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study

et al. 2023

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“…Cerebral vasospasm and delayed cerebral ischemia may lead to cerebral ischemia or brain hypoxia. These could be direct or indirectly cause by excess lactate production in the tissue, causing hyperventilation and hypocapnia ( 20 ) that could increase vasoconstriction and decrease intracranial pressure ( 21 ). Although the mechanism by which hypocapnia affects the prognosis of brain injury remains unclear, several studies have reported that hypocapnia is associated with poor outcomes in patients with brain injury.…”

Section: Discussionmentioning

confidence: 99%

Plasma anion gap and risk of in-hospital mortality in patients with spontaneous subarachnoid hemorrhage

Tong²,

Wang³

et al. 2022

Front. Neurol.

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BackgroundThe association between the serum anion gap (AG) and prognosis of patients with spontaneous subarachnoid hemorrhage (SAH) remains unknown. Thus, this study aimed to explore the association between AG levels and mortality in patients with SAH in the intensive care unit (ICU).MethodsThis was a retrospective analysis of data stored in the Medical Information Mart for Intensive Care–IV and eICU Collaborative Research databases. Critically ill patients diagnosed with spontaneous SAH were included. The primary outcome measure was in-hospital all-cause mortality. A multivariate Cox proportional hazards regression model and a restricted cubic spline were used to evaluate the relationship between AG concentration and outcomes. Kaplan–Meier curves were used to compare cumulative survival among patients with AG levels.ResultsA total of 1,114 patients were enrolled. AG concentration was significantly associated with in-hospital all-cause mortality [hazard ratio ([HR], 1.076 (95% confidence interval (CI), 1.021–1.292; p = 0.006)]. The risk of mortality was higher in the Category 2 group (AG ≥10 mmol/L and <13 mmol/L; HR, 1.961; 95% CI, 1.157–3.324; p = 0.0) and the Category 3 group (AG ≥13 mmol/L; HR, 2.151; 95% CI, 1.198–3.864; p = 0.010) than in the Category 1 group (AG < 10 mmol/L). Cumulative survival rates were significantly lower in patients with higher AG levels (log-rank p < 0.001).ConclusionsIn-hospital and ICU mortalities increase with increasing AG concentration in patients with SAH. An increased serum AG level is an independent, significant, and robust predictor of all-cause mortality. Thus, serum AG levels may be used in the risk stratification of SAH.

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“…Interestingly, ischemic brain volume increased even when jugular venous saturation (SjO 2 ) measurements, used for the assessment of global brain oxygen demands, were within the acceptable range. More recent studies report acceptable cerebral oxygenation and blood flow parameters during mild hyperventilation [ 27 , 28 , 29 , 30 ]. A practical approach, based on current evidence, is the application of mild hyperventilation with concomitant use of multimodal neuromonitoring, including methods for the focal and global assessment of the cerebral oxygenation adequacy [ 8 , 10 , 31 ].…”

Section: Tier-two Therapiesmentioning

confidence: 99%

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

Vrettou

Mentzelopoulos

2022

JCM

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Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.

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Hyperventilation in Severe Traumatic Brain Injury Has Something Changed in the Last Decade or Uncertainty Continues? A Brief Review

Cited by 7 publications

References 29 publications

Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study

Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study

Plasma anion gap and risk of in-hospital mortality in patients with spontaneous subarachnoid hemorrhage

Second- and Third-Tier Therapies for Severe Traumatic Brain Injury

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