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Severe traumatic brain injury in pediatric patients: treatment and outcome using an intracranial pressure targeted therapy–the Lund concept
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Neurosurgery.
Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
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2005 (English)In: Intensive Care Medicine, ISSN 0342-4642, E-ISSN 1432-1238, Vol. 31, no 6, 832-839 p.Article in journal (Refereed) Published
Abstract [en]

Objective: This study evaluated the outcome of treatment according to the Lund concept in children with severe traumatic brain injury and investigated whether the preset goals of the protocol were achieved.

Design and setting: A two-center retrospective study in neurointensive care units at university hospitals.

Patients: Forty-one children with severe traumatic brain injury from blunt trauma and arriving at hospital within 24 h after injury. Median age was 8.8 years (range 3 months–14.2 years), Glasgow Coma Scale 7 (3–8), and Injury Severity Score 25 (16–75). All children had pathological findings on initial computed tomography. All developed intracranial hypertension, and survivors required intensive care longer than 72 h.

Interventions: Treatment according to the principles of the Lund concept.

Measurements and results: Neurosurgery was required in 46% of the children. Survival rate was 93% and favorable outcome (Glasgow Outcome Score 4 or 5) was 80% at long-term follow-up (median 12 months postinjury, range 2.5–26). The preset physiological and biochemical goals were achieved in over 90% of observations.

Conclusions: Treating pediatric patients with severe traumatic brain injury, according to the Lund concept, results in a favorable outcome when the protocol is followed.

Place, publisher, year, edition, pages
Heidelberg: Springer-Vlg , 2005. Vol. 31, no 6, 832-839 p.
Keyword [en]
adolescent, algorithms, brain injuries/mortality/physiopathology/therapy, child, child; preschool, female, humans, infant, intensive care units, intracranial pressure, male, retrospective studies, statistics; nonparametric, survival rate, Sweden/epidemiology, wounds; nonpenetrating/mortality/physiopathology/therapy
URN: urn:nbn:se:umu:diva-5854DOI: 10.1007/s00134-005-2632-2PubMedID: 15838678OAI: diva2:145522
Available from: 2008-01-11 Created: 2008-01-11 Last updated: 2011-04-01Bibliographically approved
In thesis
1. Severe cerebral emergency: aspects of treatment and outcome in the intensive care patient
Open this publication in new window or tab >>Severe cerebral emergency: aspects of treatment and outcome in the intensive care patient
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Severe Traumatic Brain Injury (TBI) and aneurysmal Subarachnoid Hemorrhage (SAH) are severe cerebral emergencies. They are common reasons for extensive morbidity and mortality in young people and adults in the western world. This thesis, based on five clinical studies in patients with severe TBI (I-IV) and SAH (V), is concentrated on examination of pathophysiological developments and of evaluation of therapeutic approaches in order to improve outcome after cerebral emergency.

The treatment for severe TBI patients at Umeå University Hospital, Sweden is an intracranial pressure (ICP)-targeted therapy according to “the Lund-concept”. This therapy is based on physiological principles for cerebral volume regulation, in order to preserve a normal cerebral microcirculation and a normal ICP. The main goal is to avoid development of secondary brain injuries, thus avoiding brain oedema and worsened microcirculation.

Study I is evaluating retrospectively 41 children with severe TBI, from 1993 to 2002. The boundaries of the ICP-targeted protocol were obtained in 90%. Survival rate was 93%, and favourable outcome (Glasgow Outcome Scale, score 4+5) was 80%.

Study II is retrospectively analysing fluid administration and fluid balance in 93 adult patients with severe TBI, from 1998 to 2001.The ICP-targeted therapy used, have defined fluid strategies. The total fluid balance was positive day one to three, and negative day four to ten. Colloids constituted 40-60% of total fluids given/day. Severe organ failure was evident for respiratory insufficiency and observed in 29%. Mortality within 28 days was 11%.

Study III is a prospective, randomised, double-blind, placebo-controlled clinical trial in 48 patients with severe TBI. In order to improve microcirculation and prevent oedema formation, prostacyclin treatment was added to the ICP-targeted therapy. Prostacyclin is endogenously produced, by the vascular endothelium, and has the ability to decrease capillary permeability and vasodilate cerebral capillaries. Prostacyclin is an inhibitor of leukocyte adhesion and platelet aggregation. There was no significant difference between prostacyclin or placebo groups in clinical outcome or in cerebral microdialysis markers such as lactatepyruvate ratio and brain glucose levels.

Study IV is part of the third trial and focus on the systemic release of pro-inflammatory mediators that are rapidly activated by trauma. The systemically released pro-inflammatory mediators, interleukin-6 and CRP were significantly decreased in the prostacyclin group versus the placebo group.

Study V is a prospective pilot study which analyses asymmetric dimethylarginine (ADMA) concentrations in serum from SAH patients. Acute SAH patients have cerebral vascular, systemic circulatory and inflammatory complications. ADMA is a marker in vascular diseases which is correlated to endothelial dysfunction. ADMA concentrations in serum were significantly elevated seven days after the SAH compared to admission and were still elevated at the three months follow-up.

Our results show overall low mortality and high favourable outcome compared to international reports on outcome in severe TBI patients. Prostacyclin administration does not improve cerebral metabolism or outcome but significantly decreases the levels of pro-inflammatory mediators. SAH seems to induce long-lasting elevations of ADMA in serum, which indicates persistent endothelial dysfunction. Endothelial dysfunction may influence outcome after severe cerebral emergencies.

Place, publisher, year, edition, pages
Umeå: , 2009. 83 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1244
severe traumatic brain injury, intracranial pressure-targeted therapy, albumin, prostacyclin, endothelial dysfunction, pro-inflammatory cytokines, subarachnoid haemorrhage, asymmetric dimethylarginine
National Category
Anesthesiology and Intensive Care
Research subject
urn:nbn:se:umu:diva-21065 (URN)978-91-7264-725-1 (ISBN)
Anestesiologi och intensivvård, 901 87, Umeå
Public defence
2009-04-24, Sal B 9tr, Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå, 13:00 (Swedish)
Available from: 2009-04-09 Created: 2009-04-02 Last updated: 2010-01-18Bibliographically approved

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