Fluid Balance, Complications, and Brain Tissue Oxygen Tension Monitoring Following Severe Traumatic Brain Injury
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ORIGINAL ARTICLE
Fluid Balance, Complications, and Brain Tissue Oxygen Tension Monitoring Following Severe Traumatic Brain Injury Jeffrey J. Fletcher • Karen Bergman • Paul A. Blostein • Andreas H. Kramer
Published online: 8 April 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Background Refractory intracranial hypertension (RIH) frequently complicates severe traumatic brain injury (TBI) and is associated with worse outcomes. Aggressive fluid resuscitation contributes to the development of peripheral and pulmonary edema, but an effect on cerebral edema is not well established. Some clinicians, including advocates of the ‘‘Lund Concept’’, practice fluid restriction as a means of limiting cerebral edema and reducing intracranial pressure (ICP). Methods We performed a retrospective cohort study involving 41 consecutive patients with severe TBI to assess the association between fluid balance and the development of RIH or pulmonary complications. Results There was no difference in cumulative fluid balance between patients who did, or did not, develop RIH. Patients in the tertile with the largest fluid balance were no
J. J. Fletcher (&) Department of Neurosurgery, University of Michigan Hospitals and Health Center, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5338, USA e-mail: [email protected]; [email protected] J. J. Fletcher K. Bergman P. A. Blostein Department of Trauma Surgery and Critical Care, Bronson Methodist Hospital, 601 John Street, Kalamazoo, MI 49007, USA e-mail: [email protected] A. H. Kramer Departments of Critical Care Medicine & Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, 1403 29th St, N.W., Calgary, AB T2N 2T9, Canada e-mail: [email protected]
more likely to develop RIH than those in the more restrictive groups (HR 1.05, 0.78–1.42, P = 0.73). In contrast, there was a strong association between fluid balance and the development of bilateral pulmonary infiltrates, which persisted even after adjusting for Glasgow Coma Scale and Injury Severity Score (HR 1.69, 1.40– 2.04, P < 0.0001). The use of PbtO2 monitors to guide therapy was associated with higher cumulative fluid balance, more vasopressor use, and the development of both pulmonary edema and RIH. Conclusion We found no association between cumulative fluid balance and the development of RIH. However, more judicious volume management has the potential to reduce the occurrence of pulmonary complications. Further research is needed to clarify optimal approaches to fluid management among patients with severe TBI and to guide the interpretation and integration of information derived from PbtO2 monitors. Keywords Fluid balance Traumatic brain injury Refractory intracranial hypertension Pulmonary edema Brain tissue oxygen tension
Background Following severe traumatic brain injury (TBI), cerebral blood flow (CBF) autoregulation often becomes impaired and the blood–brain barrier disrupted. These pathophysiologic changes predispose pat
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