Early Cerebral Metabolic Crisis After TBI Influences Outcome Despite Adequate Hemodynamic Resuscitation
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ORIGINAL ARTICLE
Early Cerebral Metabolic Crisis After TBI Influences Outcome Despite Adequate Hemodynamic Resuscitation Nathan R. Stein • David L. McArthur Maria Etchepare • Paul M. Vespa
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Published online: 24 April 2012 Ó Springer Science+Business Media, LLC 2012
Abstract Background Optimal resuscitation after traumatic brain injury (TBI) remains uncertain. We hypothesize that cerebral metabolic crisis is frequent despite adequate resuscitation of the TBI patient and that metabolic crisis negatively influences outcome. Methods We assessed the effectiveness of a standardized trauma resuscitation protocol in 89 patients with moderate to severe TBI, and determined the frequency of adequate resuscitation. Prospective hourly values of heart rate, blood pressure, pulse oximetry, intracranial pressure (ICP), respiratory rate, jugular venous oximetry, and brain extracellular values of glucose, lactate, pyruvate, glycerol, and glutamate were obtained. The incidence during the initial 72 h after injury of low brain glucose 25, and metabolic crisis, defined as the simultaneous occurrence of both low glucose and high LPR, were determined for the group. Results 5 patients were inadequately resuscitated and eight patients had intractable ICP. In patients with successful resuscitation and controlled ICP (n = 76), within 72 h of trauma, 76 % had low glucose, 93 % had elevated
Electronic supplementary material The online version of this article (doi:10.1007/s12028-012-9708-y) contains supplementary material, which is available to authorized users. N. R. Stein D. L. McArthur M. Etchepare P. M. Vespa (&) Department of Neurosurgery, David Geffen School of Medicine at UCLA, 757 Westwood Blvd, RR 6236A, Los Angeles, CA 90095, USA e-mail: [email protected] P. M. Vespa Department of Neurology, David Geffen School of Medicine at UCLA, 757 Westwood Blvd, RR 6236A, Los Angeles, CA 90095, USA
LPR, and 74 % were in metabolic crisis. The duration of metabolic crisis was longer in those patients with unfavorable (GOSe B 6) versus favorable (GOSe C 7) outcome at 6 months (P = 0.011). In four multivariate models the burden of metabolic crisis was a powerful independent predictor of poor outcome. Conclusions Metabolic crisis occurs frequently after TBI despite adequate resuscitation and controlled ICP, and is a strong independent predictor of poor outcome at 6 months. Keywords Brain trauma Glucose Lactate Lactate/pyruvate ratio Microdialysis Resuscitation
Introduction Traumatic Brain Injury (TBI) is a major cause of death and disability. In the United States, there are 52,000 deaths annually due to TBI, accounting for nearly 1/3 of all trauma-related deaths [1]. The initial treatment of TBI has improved through the formalization of trauma triage protocols and treatment guidelines [2], with a resultant reduction in mortality from 39 % in 1987 to 27 % in 1996. Resuscitation is particularly important in patients with TBI since early physiological compromise such as hypoxemia, hypotension, and elevated intracranial pressure
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