In a trial comparing decompressive craniectomy with medical therapy in patients with traumatic brain injury and raised intracranial pressure refractory to medical therapy, decompressive craniectomy ...resulted in lower mortality and higher rates of vegetative state and severe disability.
After traumatic brain injury (TBI), intracranial pressure can be elevated owing to a mass effect from intracranial hematomas, contusions, diffuse brain swelling, or hydrocephalus.
1
Intracranial hypertension can lead to brain ischemia by reducing the cerebral perfusion pressure.
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Intracranial hypertension after TBI is associated with an increased risk of death in most studies.
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,
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The monitoring of intracranial pressure and the administration of interventions to lower intracranial pressure are routinely used in patients with TBI, despite the lack of level 1 evidence.
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Decompressive craniectomy is a surgical procedure in which a large section of the skull is removed and the underlying . . .
Background
Medical–legal partnerships integrate lawyers into health care to identify and address legal problems that can create and perpetuate disparities in health for patients and their families. ...They have previously been utilised for patients who are at high-risk of being disadvantaged such as the elderly, the disabled and those affected by chronic diseases. We have used a partnership to address the legal needs of patients with acute, critical illness including major trauma.
Method
In 2007, a free, comprehensive legal advice service was established at University Hospital Southampton NHS Foundation Trust. The service is bound by strict guidelines which have been endorsed by NHS England. The legal service is specifically prevented from acting against the NHS. A retrospective analysis of the service over a period of 11 years was undertaken to look at the range of legal advice sought. Where a potential compensation claim against a third party was identified, the percentage of cases where the legal service was instructed was noted and the outcome for those cases was examined in further detail.
Results
Five hundred and fifty-one patients and or their families have been referred to the legal service. Of these, 343 had sustained major trauma. Over 2300 hours of free legal advice were provided on non-compensation issues, primarily related to welfare benefits, local authority assistance, obtaining power of attorney or seeking Deputyship from the Court of Protection and claims against existing insurance policies. Two hundred and seventy-five of the 551 patients (50%) were found to have a potential compensation claim against a third party. The legal service was instructed to pursue a claim in 82 cases. Interim payments of nearly £13 million were provided and £128 million of compensation has been awarded in 51 cases that have been settled.
Discussion
Medical–legal partnerships are well-established in the USA. We have demonstrated that in UK, there is a demand for early legal advice for patients who have sustained critical illness including major trauma. More data are required to identify the rehabilitation outcomes for patients who have received legal support. A similar medical–legal partnership should be considered at every acute NHS Trust.
IMPORTANCE: Trials often assess primary outcomes of traumatic brain injury at 6 months. Longer-term data are needed to assess outcomes for patients receiving surgical vs medical treatment for ...traumatic intracranial hypertension. OBJECTIVE: To evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with decompressive craniectomy or standard medical care. DESIGN, SETTING, AND PARTICIPANTS: Prespecified secondary analysis of the Randomized Evaluation of Surgery With Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) randomized clinical trial data was performed for patients with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Enrollment occurred between January 2004 and March 2014. Data were analyzed between 2018 and 2021. Eligibility criteria were age 10 to 65 years, traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure for 1 to 12 hours despite pressure-controlling measures. Exclusion criteria were bilateral fixed and dilated pupils, bleeding diathesis, or unsurvivable injury. INTERVENTIONS: Patients were randomly assigned 1:1 to receive a decompressive craniectomy with standard care (surgical group) or to ongoing medical treatment with the option to add barbiturate infusion (medical group). MAIN OUTCOMES AND MEASURES: The primary outcome was measured with the 8-point Extended Glasgow Outcome Scale (1 indicates death and 8 denotes upper good recovery), and the 6- to 24-month outcome trajectory was examined. RESULTS: This study enrolled 408 patients: 206 in the surgical group and 202 in the medical group. The mean (SD) age was 32.3 (13.2) and 34.8 (13.7) years, respectively, and the study population was predominantly male (165 81.7% and 156 80.0%, respectively). At 24 months, patients in the surgical group had reduced mortality (61 33.5% vs 94 54.0%; absolute difference, −20.5 95% CI, −30.8 to −10.2) and higher rates of vegetative state (absolute difference, 4.3 95% CI, 0.0 to 8.6), lower or upper moderate disability (4.7 −0.9 to 10.3 vs 2.8 −4.2 to 9.8), and lower or upper severe disability (2.2 −5.4 to 9.8 vs 6.5 1.8 to 11.2; χ27 = 24.20, P = .001). For every 100 individuals treated surgically, 21 additional patients survived at 24 months; 4 were in a vegetative state, 2 had lower and 7 had upper severe disability, and 5 had lower and 3 had upper moderate disability, respectively. Rates of lower and upper good recovery were similar for the surgical and medical groups (20 11.0% vs 19 10.9%), and significant differences in net improvement (≥1 grade) were observed between 6 and 24 months (55 30.0% vs 25 14.0%; χ22 = 13.27, P = .001). CONCLUSIONS AND RELEVANCE: At 24 months, patients with surgically treated posttraumatic refractory intracranial hypertension had a sustained reduction in mortality and higher rates of vegetative state, severe disability, and moderate disability. Patients in the surgical group were more likely to improve over time vs patients in the medical group. TRIAL REGISTRATION: ISRCTN Identifier: 66202560
Induced Hypothermia in Trauma Bulstrode, Harry JCJ; Harrisson, Stuart E; Jacobs, Neal ...
Journal of the Intensive Care Society,
10/2011, Letnik:
12, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Induced hypothermia has established indications in cardiac arrest in adults and in hypoxic-ischaemic encephalopathy in infants. Despite substantial research effort its application in the setting of ...trauma remains controversial. In head and spinal trauma mild cooling may help to limit secondary injury. In penetrating trauma, profound cooling at the time of cardiac arrest may offer an extended window to control haemorrhage before irreversible ischaemic brain damage occurs. Both of these potential indications are the subject of clinical trials. This review seeks to set in context these studies and previous work in this field.
Decompressive craniectomy (DC) is an effective method of controlling rising intracranial pressure (ICP) refractory to medical treatment in a range of conditions: traumatic brain injury in both adults ...and children, malignant middle cerebral artery infarction and following subarachnoid haemorrhage. Herein, we describe its indications, prognosis, current operative methods and postoperative management.
. Objectives: To determine whether a hypertonic saline bolus improves cardiac conduction or plasma potassium levels more than normal saline infusion within 15 minutes of treatment for severe ...hyperkalemia. Previously with this model, 8.4% sodium chloride (NaCl) and 8.4% sodium bicarbonate (NaHCO3) lowered plasma potassium equally effectively. Methods: This was a crossover study using ten conditioned dogs (14‐20 kg) that received, in random order, each of three intravenous (IV) treatments in separate experiments at least one week apart: 1) 2 mmol/kg of 8.4% NaCl over 5 minutes (bolus); 2) 2 mmol/kg of 0.9% NaCl over one hour (infusion); or 3) no treatment (control). Using isoflurane anesthesia and ventilation (pCO2= 35‐40 torr), 2 mmol/kg/hr of IV potassium chloride (KCl) was infused until conduction delays (both absent p‐waves and ≥20% decrease in ventricular rate in ≤5 minutes) were sustained for 15 minutes. The KCl was then decreased to 1 mmol/kg/hr (maintenance) for 2 hours and 45 minutes. Treatment (0 minutes) began after 45 minutes of maintenance KCl. Results: From 0 to 15 minutes, mean heart rate increased 29.6 (95% CI = 12.2 to 46; p < 0.005) beats/min more with bolus than infusion and 23.4 (95% CI = 2.6 to 43.5; p < 0.03) beats/min more with bolus than control. No clinically or statistically significant difference was seen in heart rate changes from 0 to 30 minutes. Decreases in potassium from 0 to 15 minutes were similar with bolus, infusion, and control. Conclusions: In this model, 8.4% NaCl bolus reversed cardiac conduction abnormalities within the first 15 minutes after treatment, more rapidly than did the 0.9% NaCl infusion or control. This reversal occurred despite similar reductions in potassium levels.
We present a case of a previously healthy 19-year-old man who was admitted to our intensive care unit (ICU) with meningitis and signs of cerebral coning. Investigation confirmed raised intracranial ...pressure (ICP) with cerebellar tonsillar herniation and cerebral venous thrombosis. Blood polymerase chain reaction (PCR) demonstrated evidence of Neisseria meningitides, serogroup Y. Besides antibiotics and steroids, treatment included intubation and ventilation to maintain a PaO2 >11 kPa, PaCO2 approximately 4.5 kPa, maintenance of a mean arterial pressure >80 mm Hg, regular IV mannitol, therapeutic anticoagulation and an external ventricular drain. Three weeks following admission, he was fully alert and orientated with no focal neurological deficits. Although elevated ICP is expected in cases of meningitis, we have demonstrated that aggressive measures to reduce ICP are worthwhile, even in the presence of clinical signs of coning, which in this case resulted in a good outcome.
Changes in cell-type composition of tissues are associated with a wide range of diseases and environmental risk factors and may be causally implicated in disease development and progression. However, ...these shifts in cell-type fractions are often of a low magnitude, or involve similar cell subtypes, making their reliable identification challenging. DNA methylation profiling in a tissue like blood is a promising approach to discover shifts in cell-type abundance, yet studies have only been performed at a relatively low cellular resolution and in isolation, limiting their power to detect shifts in tissue composition.
Here we derive a DNA methylation reference matrix for 12 immune-cell types in human blood and extensively validate it with flow-cytometric count data and in whole-genome bisulfite sequencing data of sorted cells. Using this reference matrix, we perform a directional Stouffer and fixed effects meta-analysis comprising 23,053 blood samples from 22 different cohorts, to comprehensively map associations between the 12 immune-cell fractions and common phenotypes. In a separate cohort of 4386 blood samples, we assess associations between immune-cell fractions and health outcomes.
Our meta-analysis reveals many associations of cell-type fractions with age, sex, smoking and obesity, many of which we validate with single-cell RNA sequencing. We discover that naïve and regulatory T-cell subsets are higher in women compared to men, while the reverse is true for monocyte, natural killer, basophil, and eosinophil fractions. Decreased natural killer counts associated with smoking, obesity, and stress levels, while an increased count correlates with exercise and sleep. Analysis of health outcomes revealed that increased naïve CD4 + T-cell and N-cell fractions associated with a reduced risk of all-cause mortality independently of all major epidemiological risk factors and baseline co-morbidity. A machine learning predictor built only with immune-cell fractions achieved a C-index value for all-cause mortality of 0.69 (95%CI 0.67-0.72), which increased to 0.83 (0.80-0.86) upon inclusion of epidemiological risk factors and baseline co-morbidity.
This work contributes an extensively validated high-resolution DNAm reference matrix for blood, which is made freely available, and uses it to generate a comprehensive map of associations between immune-cell fractions and common phenotypes, including health outcomes.
OBJECTIVE To determine whether peptic activity in bronchoalveolar fluid, due to the presence of the gastric proteolytic enzyme pepsin, could serve as a biochemical marker for pulmonary aspiration of ...gastric contents.
DESIGN Prospective, experimental trial.
SETTING A university animal research laboratory.
SUBJECTS Thirty-six New Zealand rabbits, weighing 2 to 4 kg.
INTERVENTIONS New Zealand rabbits were anesthetized, intubated via tracheostomy, and mechanically ventilated. Pulmonary aspiration was induced by the intratracheal instillation of 2 mL/kg human gastric juice (pH 1.2 +/- 0.2; pepsin activity 0.02 +/- 0.006 micro gram/mL; human gastric juice group, n = 24) or normal saline solution (pH 5.2 +/- 0.2; normal saline solution group; n = 12). Mechanical ventilation was continued. Bronchoalveolar lavage was performed at 15 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), 30 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), or 60 mins (human gastric juice group, n = 8; normal saline solution group, n = 4) postaspiration.
MEASUREMENTS AND MAIN RESULTS Peak airway pressure and PaO2 values were measured at baseline and 15 and 30 mins after aspiration. The pH of retrieved bronchoalveolar lavage fluid was measured and pepsin activity in sample fluid was determined.Changes from baseline in peak airway pressure and Pao sub 2 were significant in human gastric juice animals at 15 and 30 mins when compared with normal saline solution animals (PaO sub 2 -4% vs. -44%, peak airway pressure 20% vs. 36% at 15 mins; PaO2 -16% vs. -79%, peak airway pressure 28% vs. 69% at 30 mins; normal saline solution group vs. human gastric juice group, p < .02). Bronchoalveolar lavage fluid pH was not significantly different between groups at any time postaspiration (6.6 +/- 0.7 vs. 6.0 +/- 0.4 at 15 mins; 7.4 +/- 0.9 vs. 6.5 +/- 0.4 at 30 mins; 7.2 +/ 0.5 vs. 6.4 +/- 0.4 at 60 mins, normal saline solution group vs. human gastric juice group, p = NS). No peptic activity was present in bronchoalveolar lavage fluid from normal saline solution animals at any time. In the human gastric juice group, peptic activity was detected in postaspiration bronchoalveolar lavage fluid in eight of eight animals at 15 mins, six of eight animals at 30 mins, and five of eight animals at 60 mins (normal saline solution group vs. human gastric juice group; p < .001 at 15 mins, p < .01 at 30 mins, p = NS at 60 mins). Peptic activity of bronchoalveolar lavage fluid varied; mean values were greater at 15 mins than at 30 or 60 mins (pepsin activity0.004 +/- 0.002 micro gram/mL vs. 0.002 +/- 0.001 micro gram/mL vs. 0.0006 +/- 0.0001 micro gram/mL, respectively, p < .05).
CONCLUSIONS The results of this study suggest that peptic activity in bronchoalveolar lavage fluid can be detected up to 60 mins after induced, experimental gastric juice aspiration and may prove a clinically useful biochemical marker for episodes of occult pulmonary aspiration of gastric contents.(Crit Care Med 1996; 24:1881-1885)
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