The Deleterious Effects of Intraoperative Hypotension on Outcome in Patients With Severe Head Injuries

Pietropaoli, John A.; Rogers, Frederick B.; Shackford, Steven R.; Wald, Steven L.; Schmoker, Joseph D.; Zhuang, Jian

doi:10.1097/00005373-199209000-00011

Cited by 223 publications

(84 citation statements)

References 0 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Several observational studies 5,8 involving patients with thoracic injuries but without femoral shaft fractures as controls have demonstrated no difference in the incidence of acute respiratory distress syndrome or mortality, suggesting that it is the severity of the pulmonary injury, rather than timing or mode of fixation, that determines the likelihood of an adverse outcome. Among patients with associated head injuries, studies have shown hypotension and decreased cerebral perfusion pressure during early fracture care [48][49][50] . Still, increased mortality has not been shown when early treatment (at less than twentyfour hours) has been compared with late treatment of femoral shaft fractures 24,41,[51][52][53] .…”

Section: Discussionmentioning

confidence: 99%

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Morshed

Miclau

Bembom

et al. 2009

The Journal of Bone and Joint Surgery-American Volume

129

View full text Add to dashboard Cite

Section: Discussionmentioning

confidence: 99%

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Morshed

Miclau

Bembom

et al. 2009

The Journal of Bone and Joint Surgery-American Volume

129

View full text Add to dashboard Cite

“…4,5 It has also been shown in histological analyses of brains in patients who died following TBI that ischemia is very common. 9,10 In several studies, 8,14 hypotension has been found to be extremely detrimental to outcome following severe TBI. There are also experimental data indicating that a decline in blood pressure is responsible for sudden increases in ICP (plateau waves) and that these waves can be aborted by increasing systemic blood pressure.…”

Section: Discussionmentioning

confidence: 99%

Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?

Young¹,

Blow²,

Turrentine³

et al. 2003

FOC

View full text Add to dashboard Cite

Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement. Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.

show abstract

“…[3,17,18,20] Information from the Traumatic Coma Data Bank indicates that lowered CPP resulting from hypotension or increased ICP is associated with a poor outcome following head injury. [3,17] Pietropaoli, et al, [27] also found that intraoperative hypotension occurring in severely head injured patients undergoing surgical procedures within 72 hours of admission to the hospital was associated with a significant increase in mortality rates and also a significant decrease in GOS scores compared to those seen in head-injured patients who did not become hypotensive during surgery. Moreover, this same study found that intraoperative hypotension occurred frequently (32% incidence) in this group of head-injured patients.…”

Section: Discussionmentioning

confidence: 99%

“…Despite the fact that the association between hypotension and worse outcome following head injury is well known, intraoperative hypotension remains relatively common in head-injured patients undergoing surgery. [27] Other options for avoiding secondary ischemic damage in these patients include preoperative or intraoperative autoregulation testing to identify those patients with poor autoregulation and monitoring jugular venous O2 saturation in affected patients to optimize CPP. [31] Further studies are needed to determine the precise mechanisms responsible for impaired autoregulation after head injury, the time course of the impairment, and to evaluate possible strategies for improvment of the autoregulatory response.…”

Section: Discussionmentioning

confidence: 99%

Cerebral autoregulation following minor head injury

North

McNamee²,

Wu³

et al. 1997

FOC

View full text Add to dashboard Cite

The purpose of this study was to determine whether patients with minor head injury experience impairments in cerebral autoregulation. Twenty-nine patients with minor head injuries defined by Glasgow Coma Scale (GCS) scores of 13 to 15 underwent testing of dynamic cerebral autoregulation within 48 hours of their injury using continuous transcranial Doppler velocity recordings and blood pressure recordings. Twenty-nine age-matched normal volunteers underwent autoregulation testing in the same manner to establish comparison values. The function of the autoregulatory response was assessed by the cerebral blood flow velocity response to induced rapid brief changes in arterial blood pressure and measured as the autoregulation index (ARI).Eight (28%) of the 29 patients with minor head injury demonstrated poorly functioning or absent cerebral autoregulation versus none of the controls, and this difference was highly significant (p = 0.008). A significant correlation between lower blood pressure and worse autoregulation was found by regression analysis in head-injured patients (r = 0.6, p < 0.001); however, lower blood pressure did not account for the autoregulatory impairment in all patients. Within this group of head-injured patients there was no correlation between ARI and initial GCS or 1-month Glasgow Outcome Scale scores. This study indicates that a significant number of patients with minor head injury may have impaired cerebral autoregulation and may be at increased risk for secondary ischemic neuronal damage.

show abstract

The Deleterious Effects of Intraoperative Hypotension on Outcome in Patients With Severe Head Injuries

Cited by 223 publications

References 0 publications

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma

Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?

Cerebral autoregulation following minor head injury

Contact Info

Product

Resources

About