Prevention of secondary ischemic insults after severe head injury

Claudia S. Robertson, Alex B. Valadka, H. Julia Hannay, Charles F. Contant, Shankar P. Gopinath, Manuela Cormio, Masahiko Uzura, Robert G. Grossman

Research output: Contribution to journalArticle

547 Scopus citations

Abstract

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 ICF-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.

Original languageEnglish (US)
Pages (from-to)2086-2095
Number of pages10
JournalCritical Care Medicine
Volume27
Issue number10
DOIs
StatePublished - Nov 10 1999

Keywords

  • Cerebral perfusion pressure
  • Intracranial hypertension
  • Jugular venous desaturation
  • Jugular venous oxygen saturation monitoring
  • Secondary ischemic insults
  • Severe head injury
  • Traumatic brain injury

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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