Prevention of secondary ischemic insults after severe head injury.
OBJECTIVE
The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.


METHODS
Randomized clinical trial.


METHODS
Level I trauma hospital.


METHODS
One hundred eighty-nine adults admitted in coma because of severe head injury.


METHODS
Patients were assigned to either cerebral blood flow (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blocks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at >70 mm Hg and PaCO2 was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2 of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension.


RESULTS
The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p = .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A low jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group. The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome.


CONCLUSIONS
Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.
Robertson
C S
CS
Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA. claudiar@bcm.tmc.edu
Valadka
A B
AB
Hannay
H J
HJ
Contant
C F
CF
Gopinath
S P
SP
Cormio
M
M
Uzura
M
M
Grossman
R G
RG
D000293:Adolescent; D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use; D001930:Brain Injuries / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D002545:Brain Ischemia / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D002405:Catheterization, Central Venous; D002560:Cerebrovascular Circulation; D003422:Critical Care / Q000379:methods*; D004234:Diuretics, Osmotic / Q000627:therapeutic use; D004322:Drainage; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D019586:Intracranial Hypertension / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D007427:Intracranial Pressure; D007601:Jugular Veins / Q000378:metabolism; D008297:Male; D010100:Oxygen / Q000097:blood; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D015599:Trauma Severity Indices; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D004234:Diuretics, Osmotic; D006993:Hypnotics and Sedatives; D010100:Oxygen