title: Early cerebral metabolic crisis after TBI influences outcome despite adequate hemodynamic resuscitation.
abstract: BACKGROUND
  Optimal resuscitation after traumatic brain injury (TBI) remains uncertain. We hypothesize that cerebral metabolic crisis is frequent despite adequate resuscitation of the TBI patient and that metabolic crisis negatively influences outcome.
  
  
  METHODS
  We assessed the effectiveness of a standardized trauma resuscitation protocol in 89 patients with moderate to severe TBI, and determined the frequency of adequate resuscitation. Prospective hourly values of heart rate, blood pressure, pulse oximetry, intracranial pressure (ICP), respiratory rate, jugular venous oximetry, and brain extracellular values of glucose, lactate, pyruvate, glycerol, and glutamate were obtained. The incidence during the initial 72 h after injury of low brain glucose <0.8 mmol/L, elevated lactate/pyruvate ratio (LPR) >25, and metabolic crisis, defined as the simultaneous occurrence of both low glucose and high LPR, were determined for the group.
  
  
  RESULTS
  5 patients were inadequately resuscitated and eight patients had intractable ICP. In patients with successful resuscitation and controlled ICP (n = 76), within 72 h of trauma, 76% had low glucose, 93% had elevated LPR, and 74% were in metabolic crisis. The duration of metabolic crisis was longer in those patients with unfavorable (GOSe ≤ 6) versus favorable (GOSe ≥ 7) outcome at 6 months (P = 0.011). In four multivariate models the burden of metabolic crisis was a powerful independent predictor of poor outcome.
  
  
  CONCLUSIONS
  Metabolic crisis occurs frequently after TBI despite adequate resuscitation and controlled ICP, and is a strong independent predictor of poor outcome at 6 months.
authors.affiliation: Department of Neurosurgery, David Geffen School of Medicine at UCLA, 757 Westwood Blvd, RR 6236A, Los Angeles, CA 90095, USA.
authors.forename: Nathan R
authors.initials: NR
authors.lastname: Stein
authors.forename: David L
authors.initials: DL
authors.lastname: McArthur
authors.forename: Maria
authors.initials: M
authors.lastname: Etchepare
authors.forename: Paul M
authors.initials: PM
authors.lastname: Vespa
mesh_terms: D000328:Adult; D001794:Blood Pressure / Q000502:physiology; D001921:Brain / Q000378:metabolism*; D001928:Brain Diseases, Metabolic / Q000453:epidemiology* / Q000378:metabolism* / Q000503:physiopathology; D001930:Brain Injuries / Q000453:epidemiology* / Q000378:metabolism* / Q000503:physiopathology; D016887:Cardiopulmonary Resuscitation / Q000592:standards / Q000706:statistics & numerical data*; D016638:Critical Illness / Q000453:epidemiology; D005260:Female; D005947:Glucose / Q000378:metabolism; D018698:Glutamic Acid / Q000378:metabolism; D005990:Glycerol / Q000378:metabolism; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D015994:Incidence; D019344:Lactic Acid / Q000378:metabolism; D008297:Male; D017551:Microdialysis / Q000379:methods; D008875:Middle Aged; D010092:Oximetry; D011237:Predictive Value of Tests; D019289:Pyruvic Acid / Q000378:metabolism
chemical_list: D019344:Lactic Acid; D018698:Glutamic Acid; D019289:Pyruvic Acid; D005947:Glucose; D005990:Glycerol