Importance of Metabolic Monitoring Systems as an Early Prognostic Indicator in Severe Head Injured Patients
We have analyzed and evaluated what is the best metabolic monitoring system to determine the prognosis for maintenance of neurological function in severe head injured patients. Acute subdural hematoma (ASDH) was recognized in fifteen of 22 patients and ce
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Importance of Metabolic Monitoring Systems as an Early Prognostic Indicator in Severe Head Injured Patients H. Kushi, T. Moriya, T. Saito, K. Kinoshita, T. Shibuya, and N. Hayashi Department of Emergency and Critical Care Medicine. Nihon University School of Medicine. Tokyo. Japan
Summary We have analyzed and evaluated what is the best metabolic monitoring system to determine the prognosis for maintenance of neurological function in severe head injured patients. Acute subdural hematoma (ASDH) was recognized in fifteen of 22 patients and cerebral contusion in seven in this series. Intracranial pressure (ICP). jugular venous pH and jugular bulb venous oxygen saturation (Sj02) were continuously monitored as soon as possible following stabilization. The measurement of cerebral blood flow (CBF) was carried out using a stable Xenon-computerized tomography (Xe-CT). After measuring CBF, 3% carbon dioxide (C0 2) loading was conducted to determine CO 2 responses (~CBF/~C02). In patients who died (D), jugular venous pH showed evidence of acidosis (6.3-7.2) with ~CBF/~C02 < I and cerebral metabolic rate of oxygen (CMR0 2) < 1.21 within several hours of the trauma. On the other hand. arterial pH was shown to be within the normal range. In vegetative state (VS) and severe disability (SD) patients. jugular venous pH was shown to be within normal range. with ~CBF/~C02 < I and 1.44 < CMR02 < 1.79. In all of moderate disability (MD) and good recovery (GR) patients, jugular venous pH was shown to be within the normal range. with ~CBF/~C02 > I and 1.65 < CMR0 2 < 1.85. These results suggest that jugular venous pH. CO 2 response and CMR0 2 , were useful as early prognostic indicators in the maintenance of neurological function. Keywords: Head injury; metabolic monitoring; jugular venous pH; jugular venous oxygen saturation.
Introduction Recently, there have been large number of reports about the treatment of severe head injured patients in intensive care unit due to the development of physiologic monitoring systems. In our institution, we utilized the measurements of ICP, Sj02, electroencephalography (EEG) mapping and auditory brainstem response (ABR), in a continuous monitoring system, also cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMR0 2) using Xe-CT. There is an established early prognostic indicator in severe head
injured. We have evaluated what we believe to be the optimal parameters to establish critical limits in severely head injured patients. Further, critical levels of hemometabolic parameters have been proposed which may provide a prognosis for maintenance of neurological function.
Methods Randomly twenty-two patients. 18-52 years of age. including 15 males and 7 females. with severe head injury but no complicated injuries. Glasgow Coma Score (GCS) of 3 to 7. were included in the study. They were admitted to the Nihon University, Emergency and Critical Care Center from January 1994 to December 1996. It took an average of 35 ± 12 minutes from the scene of the accident to arrive at our facility.
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