Analyses of the impact of energy balance on clinical outcomes in patients with severe traumatic brain injury

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Leptin plays a vital role in the regulation of energy balance in rodent models of obesity. However, less information is available about its homeostatic role in humans. The aim of this study was to determine whether leptin serves as an indicator of short-term energy balance by measuring acute effects of small manipulations in energy intake on leptin levels in normal individuals. The 12-day study was composed of four consecutive dietary-treatment periods of 3 days each. Baseline (BASE) [100% total energy expenditure (TEE)] feeding, followed by random crossover periods of overfeeding (130% TEE) or underfeeding (70% TEE) separated by a eucaloric (100% TEE) washout (WASH) period. The study participants were six healthy, nonobese subjects. Leptin levels serially measured throughout the study period allowed a daily profile for each treatment period to be constructed and a 24-h average to be calculated; ad libitum intake during breakfast "buffet" following each treatment period was also measured. Average changes in mesor leptin levels during WASH, which were sensitive to energy balance effected during the prior period, were observed. After underfeeding, leptin levels during WASH were 88 +/- 16% of those during BASE compared with 135 +/- 22% following overfeeding (P = 0.03). Leptin levels did not return to BASE during WASH when intake returned to 100% TEE, but instead were restored (104 +/- 21% and 106 +/- 16%; not significant) only after subjects crossed-over to complementary dietary treatment that restored cumulative energy balance. Changes in ad libitum intake from BASE correlated with changes in leptin levels (r2 = 0.40; P = 0.01). Leptin levels are acutely responsive to modest changes in energy balance. Because leptin levels returned to BASE only after completion of a complementary feeding period and restoration of cumulative energy balance, leptin levels reflect short-term cumulative energy balance. Leptin seems to maintain cumulative energy balance by modulating energy intake.

The effects of sleep on the relationship between brain injury severity and recovery of cognitive function: A prospective study

Kochanek, Patrick M. MD, MCCM; Herrmann, Jeremy R. MD; Bleck, Thomas P. MD, MCCM, FNCS Author Information

Objective To probe into the effect of early nursing intervention in promoting wake and complications of patients with severe traumatic brain injury. Methods 65 severe traumatic brain injury patients were divided into the control group (30 cases) and the intervention group (35 cases) randomly. The control group used conventional neurosurgical care, while in addition to conventional care, the inter-vention group also adopted early nursing intervention. The glasgow coma scale (GCS) score as well as gas-treintestinal bleeding, joint stiffness, central nervous fever and secondary infection went through comparative analysis in the two groups before and after treatment of patients using t test and χ2 test. Results Com-pared with the control group, the GCS score after treatment was higher, and the complications of gastroin-testinal bleeding, joint stiffness, central nervous fever and secondary infection were lower in the intervention group. Conclusions Early nursing intervention on patients with severe traumatic brain injury can accel-erate the awakening and reduce the occurrence of complications, it has practical significance to improve quality of life and reduce the financial burden of patients. Key words: Early nursing intervention; Severe traumatic brain injury; Promoting wake; Com-plications

As a therapeutic intervention music has a positive chance for rehabilitation of severe traumatic brain injury patients. However, many studies mention that the uses of music in health fields are still uncertainly result. This research was conducted to prove the uses of music therapy for increasing the consciousness level of severe traumatic brain injury patients and to know the physiology and psychosocial responses of patients during therapy. This study utilized a quasi-experimental method with non randomized pretest-posttest control group design. The respondents were severe traumatic brain injury patients on Cempaka and ICU wards of Prof. Dr. Margono Soekarjo Hospital Purwokerto who were chosen based on inclusion and exclusion criteria. The total of respondents was 20 respondents who were divided into 10 of respondents as treatment group and 10 respondents as control group. The analysis of data was conducted by using one sample t test and the descriptive analysis also was utilized. The study result shows that the music therapy is useful for increasing the consciousness level of severe traumatic brain injury patients (t test value = 11,781 > t table value; CI = 95%, and p value = 0.000). From descriptive data can be concluded that the response of psychology and psychosocial patients of severe traumatic brain injury in treatment group was positively significant for arousing and raising the excitability of movement performance. The result indicated that the music therapy is useful for increasing the consciousness level of severe traumatic brain injury patients and familiar music also can enhance positive response of psychology and psychosocial patients’ response.

Objective To evaluate effect of antithrombotic pressure pump on the intracranial pressure(ICP) of the severe traumatic brain injury(STBI) patients who were performed the surgery. Methods A total of 120 consecutive STBI patients after the surgery, who were admitted at Neurological Intensive Care Units (NICU) from April 2013 to September 2014, were randomly divided into (research group and control group). Each group had 60 patients. In the 6 days observation, research group received the treatment of antithrombotic pressure pump among the first 3 days after the surgery, and the treatment was stopped among the last 3 days. Control group received the opposite treatment. ICP was continuously monitored and all the data (mean ICP, times of ICP ≥20 mmHg, the highest ICP per day) were performed statistical analysis. Results Mean ICP, times of ICP ≥20 mmHg and the highest ICP per day in two groups decreased significantly after the surgery(P<0.05). The difference of Mean ICP, times of ICP ≥20 mmHg and the highest ICP per day between the two groups were not significant. No patient got the deep vein thrombosis (DVT). Conclusions Antithrombotic pressure pump could efficiently prevent deep vein thrombosis, which is a safe treatment for STBI patients and has no influence on the ICP. Key words: Severe traumatic brain injury; Intracrainal pressure; Deep vein thrombosis; Antithrombotic pressure pump

In view of assessing their late outcome and satisfaction of life, 79 out of 158 severe traumatic brain injury (STBI) patients who received inpatient rehabilitation in Aquitaine in 1993 were followed by phone interview. Results showed that 9 years on average after their injury, 65 to 85% of these patients were independent for daily living, whereas 35 to 55% only were independent in social life. Most of the patients were satisfied with their autonomy (67%), family life (66%) and financial status (41%), but they were dissatisfied with leisures (36%), vocational adjustment (28%) and sexual life (32%). Satisfaction of life was mostly related to age, gender, physical autonomy, need of help because of cognitive impairment and functional outcome as assessed by the Glasgow Outcome Scale. Severe traumatic brain injury (STBI) stands in industrialised countries as a major Public Health problem and a dreadful human drama for the patients, their families and the community [2]. A great number of STBI patients survive with severe disability, most of them being young adults. The most severely impaired may live only with their parents or in high-cost nursing homes. From a psychological point of view, STBI causes a total and sudden breakdown of the mental states, personality and conditions of life. Life plans and projects are definitively disrupted, satisfaction of life is deeply changed. Rehabilitation aims at improving functional outcome of persons with STBI, and at improving their overall quality of life. Planning for rehabilitation and re-entry into community of STBI patients need to be provided with precise data on their late outcome and disability level. Despite that the concepts of quality and satisfaction of life are difficult to define and moreover to assess, these are also major factors to take into account. The aims of the present study were to assess the late psycho-social outcome of patients hospitalized in Aquitaine for rehabilitation of a STBI 7 to 10 years after their injury, and to ask for their satisfaction of life and subjective feeling of quality of life.

Background:Cardiac dysfunction after brain death has been described in a variety of brain injury paradigms but is not well understood after severe pediatric traumatic brain injury (TBI). Cardiac dysfunction may have implications for organ donation in this patient population.Materials and Methods:We conducted a retrospective cohort study of pediatric patients with severe TBI, both with and without a diagnosis of brain death, who underwent echocardiography during the first 2 weeks after TBI, between the period of 2003–2011. We examined cardiac dysfunction in patients with and without a diagnosis of brain death.Results:In all, 32 (2.3%) of 1,413 severe pediatric TBI patients underwent echocardiogram evaluation. Most patients had head abbreviated injury score 5 (range 2–6) and subdural hematoma (34.4%). Ten patients with TBI had brain death compared with 22 severe TBI patients who did not have brain death. Four (40%) of 10 pediatric TBI patients with brain death had a low ejection fraction (EF) compared with 1 (4.5%) of 22 pediatric TBI patients without brain death who had low EF (OR = 14, P = 0.024).Conclusions:The incidence of cardiac dysfunction is higher among pediatric severe TBI patients with a diagnosis of brain death, as compared to patients without brain death. This finding may have implications for cardiac organ donation from this population and deserves further study.

Objective To understand the use of intracranial pressure (ICP)monitoring and to analyze its impact on the prognosis and economic burdens in severe traumatic brain injury (TBI) patients.Methods A multicenter study of five hospitals in Shanghai was performed.535 severe TBI patients between January 2009 and January 2011 and related clinical variables were gathered from the five hospitals.The in-hospital mortality,total hospital costs,length of stay,the cost per life year,and the cost per quality -adjusted life year(QALY) between the ICP group and the non-ICP group were compared.Results The ratio of ICP monitoring in patients with severe traumatic brain injury was 28.0％.The in-hospital mortality in the ICP group was 16.7％,which was significantly lower than the in-hospital mortality in the non-ICP group(32.2％)(P ＜0.001).Multivariate logistic regression analysis showed that the risk of death in the ICP group was only 0.32 times (95％ CI,0.19,0.54) than the non-ICP group.The mortality could decrease 15.5％ with ICP monitoring,but anaverage of 69,620 RMB was increased in hospital costs.The median cost per life year was 5,995 RMB in the ICP group,which was significantly higher than the non-ICP group (2,236 RMB) (P ＜0.001).The median cost per QALY was 11,558 RMB in the ICP group,which was significantly higher than the non-ICP group (3,938 RMB) (P ＜ 0.001).Conclusion The proportion of ICP monitoring in severe traumatic brain injury was still low.ICP monitoring in severe traumatic brain injury patients could reduce mortality but increase the economic burdens of patients. Key words: Severe traumatic brain injury; Intracranial pressure monitoring; Prognosis; Economic burden

The choice and curative effect analysis of early postoperative nutritional support for severe traumatic brain injury patients

Objective To explore the risk factors for second operation on remote site of severe traumatic brain injury patients after craniotomy. Methods The clinical data of 180 patients with severe traumatic brain injury were analyzed retrospectively who underwent craniotomy from February 2010 to October 2014 at Department of Neurosurgery, the 101 Hospital of PLA, Craniocerebal Injury Cure Center of PLA. Among them, 39(21.7%) patients received a second operation on the remote side. The correlation between multiple factors and second operation on remote site was analyzed, which included sex, trauma site (frontal-temporal, parietal, occipital or multiple), relationship of trauma site to hematoma location (ipsilateral, contralateral or bilateral), fracture on remote site, preoperative pupils (normal, unilateral large or bilateral large), ambient cistern (clear or unclear), midline shift (no, ≤5 mm, >5-10 mm or ≥10 mm), preoperative hypoxia, combined injuries, placement of ventricle drainage and decompressive craniotomy. Results It was suggested by multiple logistic regression that the trauma site in frontal-temporal areas with ipsilateral hematoma was the protective factor for re-operation on remote site (OR=0.222, 95% CI: 0.073-0.674, P=0.008), while the occipital trauma with contralateral hematoma (OR=4.647, 95% CI: 1.078-20.033, P=0.039), skull fracture on remote site (OR=3.133, 95% CI: 1.247-7.867, P=0.015) and decompressive craniotomy (OR=5.684, 95% CI: 1.759-18.370, P=0.004) were risk factors associated with second operation on remote site in severe traumatic brain injury patients after craniotomy. Conclusion Trauma in the occipital region with contralateral hematoma, skull fracture in distal area and decompressive craniotomy might be related to a larger chance of re-operation on remote site of severe traumatic brain injury patients after craniotomy. Sufficient attention to the patient's conditions are suggested and caution should be warranted. Key words: Craniocerebral trauma; Decompressive craniectomy; Reoperation; Risk factors; Remote site

Sir: Heidegger and colleagues reviewed the recent findings regarding the nutritional support of critically ill patients, and since most of the studies showed that enteral nutritional support was insufficient, they proposed to promote parenteral nutrition [1]. Definitively, the current manner in which enteral feeding is delivered in the ICU is inadequate regarding the target and leads to increased morbidity and perhaps mortality [2]. We also agree that tight glucose control together with prevention of catheter bloodstream-related sepsis have decreased the complications related to parenteral nutrition [3]. However, their proposition may not prevent feeding-related complications if they are not associated with a recommendation to determine precisely the calorie target. It has been known for years that most of the predictive formulas or the ACCN recommendations are far from measured requirements obtained by indirect calorimetry [4]. Most of the data available about calorie deficit and complications are based on measured energy requirements. Adding parenteral nutrition according to incorrect formulas may lead to overor underfeeding and to complications. Until now the routine use of metabolic carts remains unusual in critical care settings (17% of the Europeans PICUs in the only survey of 111 units available [5]) despite the fact that most of the authors agree that when you can use the metabolic cart, you should do so [6]. There is no randomized prospective study demonstrating the advantages of a metabolic cart in the critical care setting, but there are no such studies for other monitoring devices either. However, the added values of measurements obtained by a metabolic cart are numerous: daily changes in energy expenditure (up to 46% changes), cumulative energy balance during the ICU stay (as important as water balance), maximum negative energy balance which is best correlated with the occurrence of complications [2], and VO2 and VCO2 values that can guide level of sepsis and degree of metabolic rate. Overall, as in intensive insulin therapy based on glycemic measurements, tailored calorie intake based on metabolic cart measurements will improve the nutritional support. To demonstrate the benefits of the parenteral approach a randomized controlled trial based on measured energy requirements would be the most appropriate approach. Lord Kelvin, who helped Joule to construct the modern kinetic theory of heat, and of the centenary of whose death we are now marking stated: “When you can measure what you are speaking about, and express it in numbers, you know something about it. If you cannot measure it, you cannot improve it.” References

Subarachnoid hemorrhage patients are hypermetabolic and at risk for developing medical complications. A relationship was hypothesized between energy balance and complications following subarachnoid hemorrhage. Fifty-eight consecutive poor-grade subarachnoid hemorrhage patients (mean age, 58; range, 26-86; 66% women) were studied between 2005 and 2007. Caloric intake and energy expenditure were assessed. In-hospital complications over the first 14 days posthemorrhage were defined as renal failure, fever (>38.3 degrees C), any infection, anemia, hyperglycemia (>11 mmol/L), and myocardial infarction. Energy balance was calculated by subtracting energy expenditure from caloric intake. Enteral nutrition was begun 1 day posthemorrhage (range, 0-5 days). Recommended (mean +/- SD) caloric intake was 28 +/- 3 kcal/kg/d, and the actual was 14 +/- 5 kcal/kg/d. Enteral nutrition accounted for 67% of caloric intake; propofol and dextrose infusions accounted for 33% of caloric intake. Cumulative energy balance over the first 7 days was -117 +/- 53 kcal/kg. The average energy balance during the first 7 days after subarachnoid hemorrhage significantly correlated with the total number of infectious complications (r = -0.5, P < .001) but not medical complications (r = -0.2, P = .1). After adjustment for Hunt-Hess grade, fever, hyperglycemia, and anemia, negative energy balance during the first 7 days after subarachnoid hemorrhage correlated with the number of infectious complications (P = .01). Infectious complications after subarachnoid hemorrhage are associated with negative energy balance. Studies are needed to better understand the impact of negative energy balance on outcome after subarachnoid hemorrhage.

Objective To explore the correlations of intracranial pressure (ICP) with changes of neuron specific enolase (NSE), D-Dimer (D-D) and C-reactive protein (CRP) levels in patients with severe traumatic brain injury. Methods A serial of 35 patients with severe traumatic brain injury, admitted to our hospital from January 2012 to January 2014, were chosen as experimental group, and 20 healthy subjects performed physical examination in our Physical Examination Center at the same period were as controls. ICP monitoring was performed in these 35 patients. The patents were divided into two groups according to ICP: severely elevated ICP group (>40 mmHg) and moderately elevated ICP group (20- 40 mmHg). The NSE, D- D and CRP levels were measured, and these data were compared with those from the control group. The correlations of ICP with changes of NSE, D-D and CRP levels were analyzed. Results The levels of NSE, D- D and CRP in the severely elevated ICP group and moderately elevated ICP group were obviously higher than those in the control group ([12.11±2.35] μg/L, [0.39±0.61] mg/L, [3.72±0.69] mg/L) (P<0.05). The levels of NSE, D- D and CRP in the severely elevated ICP group ([104.08±7.90] μg/L, [1.55±0.26] mg/L, [47.66±8.60] mg/L) were also obviously higher than those in the moderately elevated ICP group ([61.89±30.35] μg/L, [0.93±0.32] mg/L, [30.87± 9.84] mg/L) (P<0.05). Significant positive correlations were noted between ICP and changes of NSE, D-D and CRP levels in the patient group (regression equation: ICP=18.598+0.256 NSE[t=7.200,P=0.000], ICP= 10.779+23.955 D-D [t=10.29,P=0.000], ICP=9.932+0.771 CRP [t=8.423,P=0.000]). Multivariant stepwise regression analysis indicated the closest correlation between ICP and D-D (multiple correlation coefficient=0.873, coefficient of determination=0.762,F=105.917,P=0.000). Conclusions Significant positive correlations can be noted between ICP and changes of NSE, D-D and CRP levels, and the closest correlation is between ICP and D-D in patients with severe traumatic brain injury. The combined application of ICP and NSE, D-D and CRP levels can promote the diagnosis and treatment of severe traumatic brain injury patients. Key words: Traumatic brain injury; Intracranial pressure; Neuron specific enolase; D- Dimer; C-reactive protein