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01-03-2008 | Original

Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury

Authors: Nino Stocchetti, Clelia Zanaboni, Angelo Colombo, Giuseppe Citerio, Luigi Beretta, Laura Ghisoni, Elisa Roncati Zanier, Katia Canavesi

Published in: Intensive Care Medicine | Issue 3/2008

Abstract

Objective

To quantify the occurrence of high intracranial pressure (HICP) refractory to conventional medical therapy after traumatic brain injury (TBI) and to describe the use of more aggressive therapies (profound hyperventilation, barbiturates, decompressive craniectomy).

Design

Prospective study of 407 consecutive TBI patients

Setting

Three neurosurgical intensive care units (ICU).

Measurements and results

Intracranial pressure (ICP) was studied during the first week after TBI; 153 patients had at least 1 day of ICP > 20 mmHg. Early surgery was necessary for 221 cases, and standard medical therapy [sedation, mannitol, cerebrospinal fluid (CSF) withdrawal, PaCO₂ 30–35 mmHg] was used in 135 patients. Reinforced treatment (PaCO₂ 25–29 mmHg, induced arterial hypertension, muscle relaxants) was used in 179 cases (44%), and second-tier therapies in 80 (20%). Surgical decompression and/or barbiturates were used in 28 of 407 cases (7%). Six-month outcome was recorded in 367 cases using the Glasgow outcome scale (GOS). The outcome was favorable (good recovery or moderate disability) in 195 cases (53%) and unfavorable (all the other categories) in 172 (47%). HICP was associated with worse outcome. Outcome for cases who had received second-tier therapies was significantly worse (43% favorable at 6 months, p = 0.03).

Conclusions

HICP is frequent and is associated with worse outcome. ICP was controlled by early surgery and first-tier therapies in the majority of cases. Profound hyperventilation, surgical decompression and barbiturates were used in various combinations in a minority of cases. The indications for surgical decompression and/or barbiturates seem restricted to less than 10% of severe TBI.

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Title: Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury
Authors: Nino Stocchetti
Clelia Zanaboni
Angelo Colombo
Giuseppe Citerio
Luigi Beretta
Laura Ghisoni
Elisa Roncati Zanier
Katia Canavesi
Publication date: 01-03-2008
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 3/2008
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-007-0948-9

At a glance: The STEP trials

Springer Medicine

Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury

Abstract

Objective

Design

Setting

Measurements and results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Objective

Design

Setting

Measurements and results

Conclusions

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