Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury.
OBJECTIVE
To evaluate the usefulness of early transcranial Doppler ultrasound (TCD) goal-directed therapy after severe traumatic brain injury initiated before invasive cerebral monitoring is available.


METHODS
Prospective, observational clinical study.


METHODS
Surgical intensive care unit, university hospital.


METHODS
Twenty-four severely brain-injured patients.


METHODS
All patients had TCD measurements immediately on admission (T0) and when invasive cerebral monitoring was available (T1). TCD was considered abnormal when two out of three measured values were outside the following limits: Vm<30 cm/s, Vd<20 cm/s, PI > 1.4. When admission TCD was abnormal, attending physicians modified treatment to increase cerebral perfusion pressure.


RESULTS
Admission TCD was performed 18+/-11 min (T0) after admission, whereas cerebral invasive monitoring was available 242+/-116 min (T1) after admission. At T0, 11 (46%) patients had abnormal TCD values (group 1) and 13 had normal TCD values (group 2); mean arterial pressure was comparable between groups. All group 1 patients received mannitol and/or norepinephrine. At T1, mean arterial pressure was increased compared to admission in group 1 (105+/-17 mmHg vs. 89+/-15 mmHg, p<0.05) and only two patients had still an abnormal TCD. Although group 1 patients had higher intracranial pressure than those of group 2 (32+/-13 mmHg vs. 22+/-10 mmHg, p<0.01), both cerebral perfusion pressure and jugular venous oxygen saturation were comparable between the groups.


CONCLUSIONS
The use of TCD at hospital admission allows identification of severely brain-injured patients with brain hypoperfusion. In such high-risk patients, early TCD goal-directed therapy can restore normal cerebral perfusion and might then potentially help in reducing the extent of secondary brain injury.
Ract
Catherine
C
AP-HP, Centre Hospitalo-Universitaire de Bicêtre, 78, rue du Général Leclerc, 94275, Le Kremlin Bicêtre Cedex, France.
Le Moigno
Sophie
S
Bruder
Nicolas
N
Vigué
Bernard
B
D000328:Adult; D001794:Blood Pressure; D001930:Brain Injuries / Q000145:classification* / Q000000981:diagnostic imaging / Q000628:therapy; D023261:Glasgow Outcome Scale / Q000706:statistics & numerical data; D006801:Humans; D015601:Injury Severity Score; D007362:Intensive Care Units; D009638:Norepinephrine / Q000627:therapeutic use; D011446:Prospective Studies; D017585:Ultrasonography, Doppler, Transcranial; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D014662:Vasoconstrictor Agents; D009638:Norepinephrine