Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Neurocritical Care
Published in: Neurocritical Care 2/2017

01-10-2017 | Original Article

Early-Onset Ventilator-Associated Pneumonia in Patients with Severe Traumatic Brain Injury: Incidence, Risk Factors, and Consequences in Cerebral Oxygenation and Outcome

Authors: Pierre Esnault, Cédric Nguyen, Julien Bordes, Erwan D’Aranda, Ambroise Montcriol, Claire Contargyris, Jean Cotte, Philippe Goutorbe, Christophe Joubert, Arnaud Dagain, Henry Boret, Eric Meaudre

Published in: Neurocritical Care | Issue 2/2017

Login to get access

Abstract

Background

Early-onset ventilator-associated pneumonia (EOVAP) occurs frequently in severe traumatic brain-injured patients, but potential consequences on cerebral oxygenation and outcome have been poorly studied. The objective of this study was to describe the incidence, risk factors for, and consequences on cerebral oxygenation and outcome of EOVAP after severe traumatic brain injury (TBI).

Methods

We conducted a retrospective, observational study including all intubated TBI admitted in the trauma center. An EOVAP was defined as a clinical pulmonary infection score >6, and then confirmed by an invasive method. Patient characteristics, computed tomography (CT) scan results, and outcome were extracted from a prospective register of all intubated TBI admitted in the intensive care unit (ICU). Data concerning the cerebral oxygenation monitoring by PbtO2 and characteristics of EOVAP were retrieved from patient files. Multivariate logistic regression models were developed to determine the risk factors of EOVAP and to describe the factors independently associated with poor outcome at 1-year follow-up.

Results

During 7 years, 175 patients with severe TBI were included. The overall incidence of EOVAP was 60.6% (47.4/1000 days of ventilation). Significant risk factors of EOVAP were: therapeutic hypothermia (OR 3.4; 95% CI [1.2–10.0]), thoracic AIS score ≥3 (OR 2.4; 95% CI [1.1–5.7]), and gastric aspiration (OR 5.2, 95% CI [1.7–15.9]). Prophylactic antibiotics administration was a protective factor against EOVAP (OR 0.3, 95% CI [0.1–0.8]). EOVAP had negative consequences on cerebral oxygenation. The PbtO2 was lower during EOVAP: 23.5 versus 26.4 mmHg (p <0.0001), and there were more brain hypoxia episodes: 32 versus 27% (p = 0.03). Finally, after adjusting for confounders, an EOVAP was an independent factor associated with unfavorable neurologic functional outcome at the 1-year follow-up (OR 2.71; 95% CI [1.01–7.25]).

Conclusions

EOVAP is frequent after a severe TBI (overall rate: 61%), with therapeutic hypothermia, severe thoracic lesion, and gastric aspiration as main risk factors. EOVAP had a negative impact on cerebral oxygenation measured by PbtO2 and was independently associated with unfavorable outcome at 1-year follow-up. This suggests that all precautions available should be taken to prevent EOVAP in this population.
Appendix
Available only for authorised users
Literature
1.
Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008;7:728–41.CrossRefPubMed
2.
Alali AS, Burton K, Fowler RA, Naimark DM, Scales DC, Mainprize TG, et al. Economic evaluations in the diagnosis and management of traumatic brain injury: a systematic review and analysis of quality. Value Health. 2015;18:721–34.CrossRefPubMed
3.
Langlois JA, Rutland-Brown W, Thomas KE: Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.
4.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81–4.CrossRefPubMed
5.
Zygun DA, Zuege DJ, Boiteau PJE, Laupland KB, Henderson EA, Kortbeek JB, et al. Ventilator-associated pneumonia in severe traumatic brain injury. Neurocrit Care. 2006;5(2):108–14.CrossRefPubMed
6.
Bronchard R, Albaladejo P, Brezac G, Geffroy A, Seince P-F, Morris W, et al. Early onset pneumonia: risk factors and consequences in head trauma patients. Anesthesiology. 2004;100(2):234–9.CrossRefPubMed
7.
Browne E, Hellyer TP, Baudouin SV. A national survey of the diagnosis and management of suspected ventilator-associated pneumonia. BMJ Open Respir Res. 2014;1:e000066.CrossRefPubMedPubMedCentral
8.
Lepelletier D, Roquilly A, Demeure dit latte D, Mahe PJ, Loutrel O, Champin P. Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical-ICU head-trauma patients. J Neurosurg Anesthesiol. 2010;22(1):32–7.CrossRefPubMed
9.
Rincón-Ferrari MD, Flores-Cordero JM, Leal-Noval SR, Murillo-Cabezas F, Cayuelas A, Muñoz-Sánchez MA, et al. Impact of ventilator-associated pneumonia in patients with severe head injury. J Trauma. 2004;57(6):1234–40.CrossRefPubMed
10.
Oddo M, Levine JM, Mackenzie L, Frangos S, Feihl F, Kasner SE, et al. Brain hypoxia is associated with short-term outcome after severe traumatic brain injury independent of intracranial hypertension and low cerebral perfusion pressure. Neurosurgery. 2011;69(5):1037–45.PubMed
11.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma. 2008;24((Suppl 1)):S7–13 (Erratum in J Neurotrauma 25:276–278, 2008).
12.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. II. Hyperosmolar therapy. J Neurotrauma. 2008;24((Suppl 1)):S14–20 (Erratum in J Neurotrauma 25:276–278, 2008).
13.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma. 2008;24((Suppl 1)):S55–8 (Erratum in J Neurotrauma 25:276–278, 2008).
14.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma. 2008;24((Suppl 1)):S59–64 (Erratum in J Neurotrauma 25:276–278, 2008).
15.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. X. Brain oxygen monitoring and thresholds. J Neurotrauma. 2008;24((Suppl 1)):S65–70 (Erratum in J Neurotrauma 25:276–278, 2008).
16.
Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, et al. Guidelines for the management of severe traumatic brain injury. XIV. Hyperventilation. J Neurotrauma. 2008;24((Suppl 1)):S87–90 (Erratum in J Neurotrauma 25:276–278, 2008).
17.
Anon. Guidelines for the management of adults with hospital-acquired ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.CrossRef
18.
Cotte J, Prunet B, Esnault P, Lacroix G, D’Aranda E, Cungi PJ, et al. Early onset pneumonia in patients with severely burned face and neck: a 5-year retrospective study. Burns. 2013;39(5):892–6.CrossRefPubMed
19.
Cinotti R, Dordonnat-Moynard A, Feuillet F, Roquilly A, Rondeau N, Lepelletier D, et al. Risk factors and pathogens involved in early ventilator-acquired pneumonia in patients with severe subarachnoid hemorrhage. Eur J Clin Microbiol Infect Dis. 2014;33:823–30.CrossRefPubMed
20.
Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, et al. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med. 1998;157:531–9.CrossRefPubMed
21.
Giantsou E, Liratzopoulos N, Efraimidou E, Panopoulou M, Alepopoulou E, Kartali-Ktenidou S, et al. Both early-onset and late-onset ventilator-associated pneumonia are caused mainly by potentially multiresistant bacteria. Intensive Care Med. 2005;31:1488–94.CrossRefPubMed
22.
Fartoukh M, Maitre B, Honore S, Cerf C, Zahar JR, Brun-Buisson C. Diagnosing pneumonia during mechanical ventilation: the clinical pulmonary infection score revisited. Am J Respir Crit Care Med. 2003;168(2):173–9.CrossRefPubMed
23.
Pelosi P, Barassi A, Severgnini P, Gomiero B, Finazzi S, Merlini G, et al. Prognostic role of clinical and laboratory criteria to identify early ventilator-associated pneumonia in brain injury. Chest. 2008;134(1):101–8.CrossRefPubMed
24.
Force AD. Acute respiratory distress syndrome: The Berlin definition. JAMA. 2012;307(23):2526–33.
25.
Chang JJ, Youn TS, Benson D, Mattick H, Andrade N, Harper CR, et al. Physiologic and functional outcome correlates of brain tissue hypoxia in traumatic brain injury. Crit Care Med. 2009;37:283–90.CrossRefPubMed
26.
De Oliveira Manoel AL, Goffi A, Marotta TR, Schweizer TA, Abrahamson S, Macdonald RL. The critical care management of poor-grade subarachnoid haemorrhage. Crit Care. 2016;20:21.CrossRefPubMedPubMedCentral
27.
28.
Acquarolo A, Urli T, Perone G, Giannotti C, Candiani A, Latronico N. Antibiotic prophylaxis of early onset pneumonia in critically ill comatose patients. A randomized study. Intensive Care Med. 2005;31(4):510–6.CrossRefPubMed
29.
Jovanovic B, Milan Z, Markovic-Denic L, Djuric O, Radinovic K, Doklestic K, et al. Risk factors for ventilator-associated pneumonia in patients with severe traumatic brain injury in a Serbian trauma centre. Int J Infect Dis. 2015;38:46–51.CrossRefPubMed
30.
Antonelli M, Moro ML, Capelli O, De Blasi RA, D’Errico RR, Conti G, et al. Risk factors for early onset pneumonia in trauma patients. Chest. 1994;105(1):224–8.CrossRefPubMed
31.
Michelet P, Couret D, Brégeon F, Perrin G, DʼJourno X-B, Pequignot V, et al. Early Onset Pneumonia in Severe Chest Trauma: a Risk Factor Analysis. J Trauma. 2010;68(2):395–400.CrossRefPubMed
32.
American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.CrossRef
33.
Park D. The microbiology of ventilator-associated pneumonia. Respir Care. 2005;50:742–63.PubMed
34.
Muscedere J, Dodek P, Keenan S, Fowler R, Cook D, Heyland D. Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. J Crit Care. 2008;23:138–47.CrossRefPubMed
35.
Perbet S, Mongardon N, Dumas F, Bruel C, Lemiale V, Mourvillier B, et al. Early-onset pneumonia after cardiac arrest: characteristics, risk factors and influence on prognosis. Am J Respir Crit Care Med. 2011;184(9):1048–54.CrossRefPubMed
36.
O’Phelan KH, Merenda A, Denny KG, Zaila KE, Gonzalez C. Therapeutic temperature modulation is associated with pulmonary complications in patients with severe traumatic brain injury. World J Crit Care Med. 2015;4(4):296–301.CrossRefPubMedPubMedCentral
37.
Polderman KH. Induced hypothermia and fever control for prevention and treatment of neurological injuries. Lancet. 2008;371:1955–69.CrossRefPubMed
38.
Crossley S, Reid J, McLatchie R, Hayton J, Clark C, MacDougall M, et al. A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury. Crit Care. 2014;18(2):R75.CrossRefPubMedPubMedCentral
39.
Kesinger MR, Kumar RG, Wagner AK, Puyana JC, Peitzman AP, Billiar TR, et al. Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge. J Trauma Acute Care Surg. 2015;78(2):396–402.CrossRefPubMedPubMedCentral
40.
Kim Y, Busto R, Dietrich WD, Kraydieh S, Ginsberg MD. Delayed postischemic hyperthermia in awake rats worsens the histopathological outcome of transient focal cerebral ischemia. Stroke. 1996;27(12):2274–80.CrossRefPubMed
41.
Bao L, Chen D, Ding L, Ling W, Xu F. Fever burden is an independent predictor for prognosis of traumatic brain injury. PLoS ONE. 2014;13(9):e90956.CrossRef
42.
Monton C, Torres A, El-Ebiary M, Filella X, Xaubet A, de la Bellacasa JP. Cytokine expression in severe pneumonia: a bronchoalveolar lavage study. Crit Care Med. 1999;27(9):1745–53.CrossRefPubMed
43.
Hang CH, Shi JX, Tian J, Li JS, Wu W, Yin HX. Effect of systemic LPS injection on cortical NF-kappaB activity and inflammatory response following traumatic brain injury in rats. Brain Res. 2004;1026(1):23–32.CrossRefPubMed
44.
Shan J, Chen HL, Zhu JH. Diagnostic accuracy of clinical pulmonary infection score for ventilator-associated pneumonia: a meta-analysis. Respir Care. 2011;56:1087–94.CrossRefPubMed
45.
Damas P, Frippiat F, Ancion A, Canivet JL, Lambermont B, Layios N, et al. Prevention of ventilator-associated pneumonia and ventilator-associated conditions: a randomized controlled trial with subglottic secretion suctioning. Crit Care Med. 2015;43:22–30.CrossRefPubMed
46.
Sirvent JM, Torres A, El-Ebiary M, Castro P, de Batlle J, Bonet A. Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med. 1997;155:1729–34.CrossRefPubMed
47.
De Smet AM, Kluytmans JA, Cooper BS, Mascini EM, Benus RF, van der Werf TS, et al. Decontamination of the digestive tract and oropharynx in ICU patients. N Engl J Med. 2009;360:20–31.CrossRefPubMed
Metadata
Title
Early-Onset Ventilator-Associated Pneumonia in Patients with Severe Traumatic Brain Injury: Incidence, Risk Factors, and Consequences in Cerebral Oxygenation and Outcome
Authors
Pierre Esnault
Cédric Nguyen
Julien Bordes
Erwan D’Aranda
Ambroise Montcriol
Claire Contargyris
Jean Cotte
Philippe Goutorbe
Christophe Joubert
Arnaud Dagain
Henry Boret
Eric Meaudre
Publication date
01-10-2017
Publisher
Springer US
Published in
Neurocritical Care / Issue 2/2017
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-017-0397-4

Other articles of this Issue 2/2017

Neurocritical Care 2/2017 Go to the issue

Current Concepts

Shunt Devices for Neurointensivists: Complications and Management

Ethical Matters

What Families Need and Physicians Deliver: Contrasting Communication Preferences Between Surrogate Decision-Makers and Physicians During Outcome Prognostication in Critically Ill TBI Patients

Editorial

Caring for Patients’ Families (or Lack of Family) in Neurocritical Care

Ethical Matters

Palliative Care Needs Assessment in the Neuro-ICU: Effect on Family

Original Article

Cold Blooded: Evaluating Brain Temperature by MRI During Surface Cooling of Human Subjects

Practical Pearl

Dual-Energy CT to Diagnose Pseudoedema in Contrast-Induced Encephalopathy Following Cerebral Angiography