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Optimizing Hemodynamics in the Clinical Setting

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Vascular Mechanisms in CNS Trauma

Part of the book series: Springer Series in Translational Stroke Research ((SSTSR,volume 5))

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Abstract

Hypotension is common following traumatic brain injury and can contribute to a poor outcome. Hypovolemia is the most common cause of hypotension in this setting, but myocardial dysfunction may also occur. Fluid resuscitation is the initial step in treating hypotension. Recent trials have failed to demonstrate an advantage of colloids or hypertonic saline over normal saline resuscitation, and albumin resuscitation was even associated with a higher mortality rate. Therefore normal saline remains the standard resuscitation fluid, even though colloids and hypertonic saline have some theoretical advantages following brain injury. The optimal hemoglobin concentration for the brain-injured patient remains controversial, and the decision to transfuse remains an assessment of the risk-benefit ratio of improving cerebral oxygen delivery with the risk of complications of transfusions. When blood pressure remains inadequate following fluid resuscitation, vasopressors may be needed. While definitive studies are lacking, available studies suggest that norepinephrine and phenylephrine have advantages over dopamine as the initial choice for vasopressor.

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References

  1. Benjamin E, Griffin K, Leibowitz AB et al (1998) Goal-directed transesophageal echocardiography performed by intensivists to assess left ventricular function: comparison with pulmonary artery catheterization. J Cardiothorac Vasc Anesth 12:10–15

    Article  PubMed  CAS  Google Scholar 

  2. Bouma GJ, Muizelaar JP, Bandoh K et al (1992) Blood pressure and intracranial pressure-volume dynamics in severe head injury: relationship with cerebral blood flow. J Neurosurg 77:15–19

    Article  PubMed  CAS  Google Scholar 

  3. Bratton SL, Chesnut RM, Ghajar J et al (2007) Guidelines for the management of severe traumatic brain injury. J Neurotrauma 24(Suppl 1):S1–S106

    Google Scholar 

  4. Brenner M, Stein DM, Hu PF et al (2012) Traditional systolic blood pressure targets underestimate hypotension-induced secondary brain injury. J Trauma Acute Care Surg 72:1135–1139

    PubMed  Google Scholar 

  5. Bulger EM, May S, Brasel KJ et al (2010) Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA 304:1455–1464

    Article  PubMed  CAS  Google Scholar 

  6. Bulger EM, May S, Kerby JD et al (2011) Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial. Ann Surg 253:431–441

    Article  PubMed  Google Scholar 

  7. Butcher I, Maas AI, Lu J et al (2007) Prognostic value of admission blood pressure in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:294–302

    Article  PubMed  Google Scholar 

  8. Chesnut RM, Marshall SB, Piek J et al (1993) Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir Suppl 59:121–125

    PubMed  CAS  Google Scholar 

  9. Contant CF, Valadka AB, Gopinath SP et al (2001) Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg 95:560–568

    Article  PubMed  CAS  Google Scholar 

  10. Cooper DJ, Myburgh J, Heritier S et al (2013) Albumin resuscitation for traumatic brain injury: is intracranial hypertension the cause of increased mortality? J Neurotrauma 30:512–518

    Article  PubMed  Google Scholar 

  11. Desjardins P, Turgeon AF, Tremblay MH et al (2012) Hemoglobin levels and transfusions in neurocritically ill patients: a systematic review of comparative studies. Crit Care 16:R54

    Article  PubMed  Google Scholar 

  12. Doyle JA, Davis DP, Hoyt DB (2001) The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma 50:367–383

    Article  PubMed  CAS  Google Scholar 

  13. Feinstein AJ, Patel MB, Sanui M et al (2005) Resuscitation with pressors after traumatic brain injury. J Am Coll Surg 201:536–545

    Article  PubMed  Google Scholar 

  14. Ferrada P, Anand RJ, Whelan J et al (2012) Qualitative assessment of the inferior vena cava: useful tool for the evaluation of fluid status in critically ill patients. Am Surg 78:468–470

    PubMed  Google Scholar 

  15. Finfer S, Bellomo R, Boyce N et al (2004) A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 350:2247–2256

    Article  PubMed  CAS  Google Scholar 

  16. Gaehtgens P, Marx P (1987) Hemorheological aspects of the pathophysiology of cerebral ischemia. J Cereb Blood Flow Metab 7:259–265

    Article  PubMed  CAS  Google Scholar 

  17. Grande PO (2006) The “Lund Concept” for the treatment of severe head trauma–physiological principles and clinical application. Intensive Care Med 32:1475–1484

    Article  PubMed  Google Scholar 

  18. Hebert PC, Wells G, Blajchman MA et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–417

    Article  PubMed  CAS  Google Scholar 

  19. Hinson HE, Stein D, Sheth KN (2013) Hypertonic saline and mannitol therapy in critical care neurology. J Intensive Care Med 28:3–11

    Article  PubMed  Google Scholar 

  20. Hlatky R, Valadka AB, Robertson CS (2005) Intracranial pressure response to induced hypertension: role of dynamic pressure autoregulation. Neurosurgery 57:917–923

    Article  PubMed  Google Scholar 

  21. Kramer AH, Le RP (2012) Red blood cell transfusion and transfusion alternatives in traumatic brain injury. Curr Treat Options Neurol (in press)

    Google Scholar 

  22. Kramer GC (2003) Hypertonic resuscitation: physiologic mechanisms and recommendations for trauma care. J Trauma 54:S89–S99

    PubMed  Google Scholar 

  23. Kroppenstedt SN, Sakowitz OW, Thomale UW et al (2002) Norepinephrine is superior to dopamine in increasing cortical perfusion following controlled cortical impact injury in rats. Acta Neurochir Suppl 81:225–227

    PubMed  CAS  Google Scholar 

  24. Kroppenstedt SN, Thomale UW, Griebenow M et al (2003) Effects of early and late intravenous norepinephrine infusion on cerebral perfusion, microcirculation, brain-tissue oxygenation, and edema formation in brain-injured rats. Crit Care Med 31:2211–2221

    Article  PubMed  CAS  Google Scholar 

  25. Leal-Noval SR, Munoz-Gomez M, Arellano-Orden V et al (2008) Impact of age of transfused blood on cerebral oxygenation in male patients with severe traumatic brain injury. Crit Care Med 36:1290–1296

    Article  PubMed  Google Scholar 

  26. Leal-Noval SR, Munoz-Gomez M, Murillo-Cabezas F (2008) Optimal hemoglobin concentration in patients with subarachnoid hemorrhage, acute ischemic stroke and traumatic brain injury. Curr Opin Crit Care 14:156–162

    Article  PubMed  Google Scholar 

  27. Marik PE, Baram M, Vahid B (2008) Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 134:172–178

    Article  PubMed  Google Scholar 

  28. Marik PE, Cavallazzi R, Vasu T et al (2009) Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the literature. Crit Care Med 37:2642–2647

    Article  PubMed  Google Scholar 

  29. Marmarou A, Anderson RL, Ward JD et al (1991) Impact of ICP instability and hypotension on outcome in patients with severe head injury. J Neurosurg 75:S59–S64

    Google Scholar 

  30. McIntyre LA, Fergusson DA, Hutchison JS et al (2006) Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 5:4–9

    Article  PubMed  Google Scholar 

  31. Melamed R, Sprenkle MD, Ulstad VK et al (2009) Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 135:1416–1420

    Article  PubMed  Google Scholar 

  32. Murray GD, Butcher I, McHugh GS et al (2007) Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:329–337

    Article  PubMed  Google Scholar 

  33. Myburgh J, Cooper DJ, Finfer S et al (2007) Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 357:874–884

    Article  PubMed  CAS  Google Scholar 

  34. Nguyen H, Zaroff JG (2009) Neurogenic stunned myocardium. Curr Neurol Neurosci Rep 9:486–491

    Article  PubMed  Google Scholar 

  35. Ract C, Vigue B (2001) Comparison of the cerebral effects of dopamine and norepinephrine in severely head-injured patients. Intensive Care Med 27:101–106

    Article  PubMed  CAS  Google Scholar 

  36. Ract C, Vigue B, Bodjarian N et al (2001) Comparison of dopamine and norepinephrine after traumatic brain injury and hypoxic-hypotensive insult. J Neurotrauma 18:1247–1254

    Article  PubMed  CAS  Google Scholar 

  37. Raghunathan K, McGee WT, Higgins T (2012) Importance of intravenous fluid dose and composition in surgical ICU patients. Curr Opin Crit Care 18:350–357

    Article  PubMed  Google Scholar 

  38. Rizoli SB, Rotstein OD, Parodo J et al (2000) Hypertonic inhibition of exocytosis in neutrophils: central role for osmotic actin skeleton remodeling. Am J Physiol Cell Physiol 279:C619–C633

    PubMed  CAS  Google Scholar 

  39. Robertson CS, Valadka AB, Hannay HJ et al (1999) Prevention of secondary ischemic insults after severe head injury. Crit Care Med 27:2086–2095

    Article  PubMed  CAS  Google Scholar 

  40. Romero-Bermejo FJ, Ruiz-Bailen M, Guerrero-De-Mier M et al (2011) Echocardiographic hemodynamic monitoring in the critically ill patient. Curr Cardiol Rev 7:146–156

    Article  PubMed  Google Scholar 

  41. Saugel B, Kirsche SV, Hapfelmeier A et al (2013) Prediction of fluid responsiveness in patients admitted to the medical intensive care unit. J Crit Care 28:537.e1–537.e9

    Article  Google Scholar 

  42. Saugel B, Ringmaier S, Holzapfel K et al (2011) Physical examination, central venous pressure, and chest radiography for the prediction of transpulmonary thermodilution-derived hemodynamic parameters in critically ill patients: a prospective trial. J Crit Care 26:402–410

    Article  PubMed  Google Scholar 

  43. Sena MJ, Rivers RM, Muizelaar JP et al (2009) Transfusion practices for acute traumatic brain injury: a survey of physicians at US trauma centers. Intensive Care Med 35:480–488

    Article  PubMed  Google Scholar 

  44. Smith MJ, Stiefel MF, Magge S et al (2005) Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med 33:1104–1108

    Article  PubMed  Google Scholar 

  45. Sookplung P, Siriussawakul A, Malakouti A et al (2011) Vasopressor use and effect on blood pressure after severe adult traumatic brain injury. Neurocrit Care 15:46–54

    Article  PubMed  CAS  Google Scholar 

  46. Steiner LA, Johnston AJ, Czosnyka M et al (2004) Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med 32:1049–1054

    Article  PubMed  Google Scholar 

  47. Stubbe HD, Greiner C, Westphal M et al (2006) Cerebral response to norepinephrine compared with fluid resuscitation in ovine traumatic brain injury and systemic inflammation. Crit Care Med 34:2651–2657

    Article  PubMed  CAS  Google Scholar 

  48. Suehiro K, Rinka H, Ishikawa J et al (2012) Stroke volume variation as a predictor of fluid responsiveness in patients undergoing airway pressure release ventilation. Anaesth Intensive Care 40:767–772

    PubMed  CAS  Google Scholar 

  49. Torella F, Haynes SL, McCollum CN (2003) Cerebral and peripheral oxygen saturation during red cell transfusion. J Surg Res 110:217–221

    Article  PubMed  CAS  Google Scholar 

  50. Utter GH, Shahlaie K, Zwienenberg-Lee M et al (2011) Anemia in the setting of traumatic brain injury: the arguments for and against liberal transfusion. J Neurotrauma 28:155–165

    Article  PubMed  Google Scholar 

  51. van den Elsen MJ, Leenen LP, Kesecioglu J (2010) Hemodynamic support of the trauma patient. Curr Opin Anaesthesiol 23:269–275

    Article  PubMed  Google Scholar 

  52. Weiskopf RB, Kramer JH, Viele M et al (2000) Acute severe isovolemic anemia impairs cognitive function and memory in humans. Anesthesiology 92:1646–1652

    Article  PubMed  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA

    Claudia S. Robertson

  2. Baylor College of Medicine, Houston, TX, USA

    Jose Alberto Toranzo

Authors
  1. Jose Alberto Toranzo
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  2. Claudia S. Robertson
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Correspondence to Claudia S. Robertson .

Editor information

Editors and Affiliations

  1. Departments of Neurology and Radiology, Massachusetts General Hospital Harvard Medical School, Boston, Massachusetts, USA

    Eng H. Lo

  2. Department of Pediatrics, Massachusetts General Hospital Harvard Medical School, Boston, Massachusetts, USA

    Josephine Lok

  3. Department of Neurology, Massachusetts General Hospital Harvard Medical School, Boston, Massachusetts, USA

    MingMing Ning

  4. Department of Pediatrics, Massachusetts General Hospital Harbard Medical School, Boston, Massachusetts, USA

    Michael J. Whalen

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Toranzo, J.A., Robertson, C.S. (2014). Optimizing Hemodynamics in the Clinical Setting. In: Lo, E., Lok, J., Ning, M., Whalen, M. (eds) Vascular Mechanisms in CNS Trauma. Springer Series in Translational Stroke Research, vol 5. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-8690-9_22

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  • DOI: https://doi.org/10.1007/978-1-4614-8690-9_22

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  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-8689-3

  • Online ISBN: 978-1-4614-8690-9

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