Coma Scale Research Articles

Effects of enteral immunonutrition supplemented with omega-3 polyunsaturated fatty acid on inflammatory response and intestinal mucosal barrier function in patients with severe traumatic brain injury

Objective To investigate the effects of enteral immunonutrition supplemented with omega-3 polyunsaturated fatty acid (ω-3 PUFA) on inflammatory response, intestinal mucosal barrier function and the prognosis in patients with severe traumatic brain injury (sTBI). Methods 122 patients of sTBI hospitalized between January 2015 and December 2016 were randomly divided into experimental group (ω-3 PUFA, n=61) and control group (n=61). The serum levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-6 and neuron specific enolase (NSE) were tested with enzyme linked immunosorbent assay. Meanwhile, D-lactate acid and intestinal fat acid binding protein (I-FABP) were evaluated by enzymology spectrophotometer method. After 14 days of treatment, the Glasgow Coma Scale (GCS) scores, Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ scores and prognoses of both groups were compared. Results The serum levels of inflammatory factors (TNF-α and IL-6), intestinal mucosal barrier function indicators (D-lactate acid and I-FABP) and NSE proteins significantly increased after sTBI (P=0.01). Compared with the control group, the experimental group on day 3 had significantly lower serum levels of inflammatory factors [TNF-α: (107.77±19.79)μg/L vs. (151.76±21.65)μg/L, P=0.01; IL-6: (76.85±7.15)μg/L vs. (105.27±10.12)μg/L, P=0.01] and intestinal mucosal barrier function indicators [D-lactate: (69.81±6.32)μg/L vs. (89.80±8.75)μg/L, P=0.03; I-FABP: (40.81±6.73)μg/L vs. (56.60±8.58)μg/L, P=0.01]. On day 7, the experimental group had significantly lower expression of NSE proteins than the control group [(13.63±2.53)μg/L vs. (19.12±3.00)μg/L, P=0.02]. The experimental group received better prognosis compared to the control group on day 14 [GCS scores: (9.74±0.76)vs. (8.44±0.53), P=0.04; APACHE Ⅱ scores: (14.67±1.37)vs. (17.53±1.47), P=0.03]. The experimental group also had fewer days in hospitalization [(19.37±2.27)d vs. (25.42±2.61)d, P=0.01]. Conclusion Enteral immunonutrition supplemented with ω-3 PUFA can effectively regulate the inflammatory response, and reduce impairment to the intestinal mucosal barrier function and damage to neurons in patients with sTBI. Key words: Craniocerebral trauma; Unsaturated fatty acids; Inflammatory response; Intestinal mucosal barrier

Severe traumatic brain injury and hospital acquired pneumonia: A study of correlation factors

Objective To investigate the incidence and risk factors of hospital acquired pneumonia (HAP) among patients with severe traumatic brain injury (TBI). Methods The clinical and imaging data of 114 adult patients diagnosed as severe TBI were retrospectively reviewed who underwent treatment at Department of Neurosurgery, Beijing Tiantan Hospital, from March 2016 to March 2017. Factors analyzed included the age, gender, mechanisms of injury, CT scan before admission, GCS (Glasgow Coma Scale) scores, pupil changes, tracheal intubation or tracheostomy, central nervous system (CNS) infection, duration of mechanical ventilation and antibiotic drug use. Comparison of variables between groups with tracheal intubation and tracheostomy, early and late tracheostomy were conducted. Results The incidence of HAP after admission was 23.8%. Past history of pulmonary diseases, tracheal manipulation, CNS infection, diffuse axonal injury were considered as risk factors of HAP. Patients in tracheal intubation group had significantly fewer days of ventilator use and shorter stay at hospital, lower incidence of HAP compared with tracheostomy group. Patients with early tracheostomy had lower incidence of skull fracture, shorter hospital stay and less expenses, while their incidence of HAP and outcomes were not significantly different from those with late tracheostomy. Conclusions Pulmonary diseases, related tracheal manipulation, CNS infection and diffuse axonal injury could be the risk factors for HAP in patients with severe TBI. Early tracheostomy might not reduce the risk of HAP, while it could significantly decrease the incidence of skull fracture, the length of hospital stay, antibiotic usage and medical expenses. Key words: Craniocerebral trauma; Pneumonia, ventilator-associated; Root cause analysis

Value of optic nerve sheath diameter in early assessment of patients with traumatic brain injury

Objective To analyze the relationship between the optic nerve sheath diameter (ONSD) and the scoring of Glasgow Coma Scale(GCS)or CT score(Rotterdam CT score or Helsinki CT score). Methods Sixty-three adult patients with traumatic brain injury in our emergency room were enrolled. All the patients were presented with the data of GCS and the classification of cranial CT, as well as ONSD measured by ultrasound. The correlation between ONSD and classification of cranial CT scores or GCS was analyzed by Spearman correlation analysis. Patients were divided into mild group, moderate group and severe group based on GCS or CT scores. One-way Analysis of Variance (ANOVA) was used to discover the difference in mean ONSD among different groups on account of scoring of GCS or cranial CT scores. The intergroup comparisons were analyzed by the least-significant-difference (LSD) tests. Results ONSD measurements were strongly correlated with GCS(r=-0.540,P<0.01)or classification of Rotterdam CT scores (r=0.654,P<0.01) and Helsinki CT scores (r=0.663,P<0.01). The mean ONSD of the mild, moderate and severe group were (3.89±0.70)mm, (4.50±0.65)mm and (4.81±0.72) mm, respectively. The mean ONSD of the mild group was significantly shorter than that of severe group (P<0.01) and moderate group(P<0.05). The same results were found when comparing mean ONSDs among different groups classified by Rotterdam CT scores (low group (3.74±0.64)mm vs. middle group (4.31±0.73)mm vs. high group (5.09±0.57)mm, P<0.01 or P<0.05) or classified by Helsinki CT scores (low group (3.54±0.61)mm vs. middle group (4.46±0.73)mm vs. high group (5.16±0.37)mm, P<0.01. Conclusions Ultrasonography used to measure ONSD is significantly correlated with both GCS and classification of head CT including Rotterdam CT score and Helsinki CT score. The results indicate that ultrasonography measurement of ONSD is helpful for early bedside assessment in patients with traumatic brain injury. Key words: Traumatic brain injury; Ultrasound; Noninvasive assessment; Optic nerve sheath diameter; Glasgow coma scale; Rotterdam CT score; Helsinki CT score; Correlation analysis

Value of minimally invasive puncturation via hard tunnel in decompression before craniotomy for acute subdural hematoma combined with cerebral hernia

Objective To explore the value of minimally invasive puncturation via the hard tunnel in decompression before craniotomy for acute subdural hematoma combined with cerebral hernia. Methods A retrospective method was adopted to analyze the clinical data of 303 patients with traumatic acute subdural hematoma combined with cerebral hernia treated from January 2004 to October 2016. There were 206 males and 97 females, with age range of 12-77 years [(43.6±20.1)years]. The Glasgow coma scale (GCS) was 3-5 points in 187 patients and 6-8 points in 116. The patients were divided into study group (n=199) and control group (n=104) according to the different surgical procedures. For study group, the patients were treated with disposable ventricular needle to suck out and drain the intracranial hematoma, and the skull was opened through the large craniotomy to remove the subdural hematoma. For control group, the skull was opened through the large craniotomy which was used to directly remove the subdural hematoma according to the traditional instruction. The differences between two groups were compared with regard to time from confirming the cerebral hernia to the first decompression, time of regaining consciousness after surgery, hospitalization duration and cranial cavity infection after surgery. Glasgow outcome scale (GOS) was used to evaluate the prognosis. Results The time to first decompression was 10-15 minutes [(12.5±1.7)minutes] in study group and 50-75 minutes [(133.0±7.9)minutes] in control group ( P<0.05). Regaining consciousness within 3 days after surgery was found in 62 patients of study group and 18 of control group. Regaining consciousness at days 4-7 after surgery was found in 76 patients of study group and 22 of control group. Regaining consciousness at days 8-15 days after surgery was found in 26 patients of study group and 29 of control group. Regaining consciousness over 15 days after surgery was found in 10 patients of study group and 12 of control group. Postoperative unconsciousness including death was found in 25 patients of study group and 23 of control group (P<0.05). The hospitalization duration was (19.5±1.1)days in study group and (22.8±2.8)days in control group(P<0.05). No cranial cavity infection was found in study group, while cranial cavity infection occurred in one patient in control group. According to the GOS, the outcome in study group was good in 133 patients, moderate to severe disability in 41, vegetative state in 7 and death in 18, while the outcome in control group was good in 34 patients, moderate to severe disability in 47, vegetative state in 9 and death in 14 (P<0.05). Conclusion The minimally invasive puncturation via the hard tunnel to remove the hematoma is capable of reducing the intracranial pressure before craniotomy for acute subdural hematoma combined with cerebral hernia, can decrease the disability rate and hence is prioritized to clinical application. Key words: Hematoma, subdural, acute; Cerebral hernia; Microinvasive puncturation

Application of diffusion tensor imaging in prognosis evaluation in patients with moderate and severe diffuse axonal injury

Objective To investigate the application of diffusion tensor imaging (DTI) in evaluating prognosis of patients with moderate and severe diffuse axonal injury (DAI). Methods A prospective cohort study was made on 35 patients with moderate and severe DAI, who were enrolled from June 2013 to December 2015 as study group. There were 21 males and 14 females, with age of (55.1±11.6) years. The Glasgow coma scale (GCS) was (8.2±2.9)points on admission. Moderate DAI was seen in 20 patients and severe DAI in 15 patients. Other 15 healthy volunteers were selected as control group. Fractional anisotropy (FA) was measured by DTI in three areas of interests as follows: the corpus callosum, thalamus, and brainstem areas. Glasgow outcome scale (GOS) was adopted to assess the prognosis of DAI patients at 6 months after the injury. The FA values of the three areas between study group and control group as well as FA values of patients when they were admitted to hospital and 6 months after injury were measured. In this way, the relationship between the FA values of different areas of interests in DAI patients on admission and the prognosis 6 months after injury was analyzed. Results The FA values of the corpus callosum, thalamus and brainstem area in study group were all lower than those in control group (P<0.05). Further, FA values of the corpus callosum, thalamus, brainstem area in severe DAI patients were lower than those of moderate DAI patients (P<0.05). FA values of the corpus callosum, thalamus, brain stem areas in DAI patients at 6 months after injury were lower than those of corresponding areas when DAI patients were admitted to hospital (P<0.05). FA values of the corpus callosum, thalamus and brain stem on admission were significantly positively correlated with GOS at 6 months after injury (P<0.05). Conclusions Lower FA values of the corpus callosum, thalamus and brainstem area in patients with moderate and severe DAI are associated with more severe injury and worse prognosis. DTI scans can be used as a valuable tool to evaluate the prognosis of DAI patients. Key words: Diffuse axonal injury; Diffusion tensor imaging; Prognosis

Effects of enteral nutrition added with glutamine on gastrointestinal functions and prognosis of acute severe traumatic brain injury

Objective To investigate the effects of enteral nutrition added with glutamine on the incidences of gastrointestinal complications, intestinal mucosal barrier function and inflammatory responses in patients with acute severe traumatic brain injury (sTBI). Methods A prospective case control study was made on 107 patients with sTBI hospitalized from January 2016 to June 2017. The patients were divided into experimental group added with glutamine (n=54) and control group without glutamine (n=53) according to the random number table. The general data of the patients were recorded. After treatment, the incidences of gastrointestinal complications in both groups were compared. The serum levels of intestinal mucosal barrier function indices, namely, diamine oxidase (DAO), D-lactate acid, and intestinal fat acid binding protein (I-FABP) were evaluated by enzymology spectrophotometer method. Meanwhile, the serum levels of C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were also tested with enzyme-linked immunosorbent assay (ELISA). Glasgow coma scale (GCS), acute physiology and chronic health evaluation II (APACHE II), and hospital stay in both groups were compared. Results The two group were comparable with respect to gender, age, injury reasons, body mass index, preoperative GCS, preoperative APACHE II, injury type and injury time (P>0.05). The experimental group had lower incidences of stress ulcer, gastric retention and diarrhea compared with the control group 14 days after treatment (P<0.05). Within 14 days after treatment, the serum levels of DAO, D-lactate acid and I-FABP were significantly decreased in the experimental group at days 7 and 14 after treatment (P<0.05). The serum levels of CRP, TNF-α and IL-6 in the experimental group were significantly decreased after treatment (P<0.05). The experimental group had better prognosis compared with the control group (P<0.05), with higher GCS scores [(9.3±0.7) points vs. (8.2±0.7) points], lower APACHE II scores [(15.3±1.1)points vs. (17.7±1.2) points] at day 14, and shorter hospital stay [(19.1±2.2)days vs. (25.3±2.4)days] (P<0.01). Conclusions Enteral nutrition added with glutamine can effectively reduce the incidence of gastrointestinal complications, as well as alleviate the intestinal mucosal barrier function damage and the inflammatory responses at early stage after sTBI, which possibly improves prognosis. Key words: Craniocerebral trauma; Enteral nutrition; Glutamine; Gastrointestinal tract; Prognosis

Analysis on risk factors of catheter-related infections of external ventricular drainage

Objective To explore the risk factors of catheter-related infections of external ventricular drainage (EVD) , so as to provide evidence for effective prevention and control measures. Methods A total of 428 patients′ clinical data were collected by retrospective case analysis in cluster sampling, who underwent external ventricular drainage in Neurosurgery Department of a class Ⅲ grade A hospital in Shanghai from January 2014 to October 2016. The incidence of EVD infection was analyzed. At the same time, univariate analysis and multivariate Logistic regression analysis were adopted for risk factors of EVD related infection. Results The catheter-related ventricular infections occurred in 36 of 428 cases of patients, with the incidence rate 8.41%. The detection rate of pathogens in cerebrospinal fluid was 75.00%, and Gram-negative bacteria were the main pathogens (78.13%) , among which the most common was Acinetobacter baumannii (28.11%) . Univariate analysis showed that the incidence of catheter-related ventricular infection was related to gender, age, admission diagnosis, diabetes mellitus, preoperative pulmonary infection, Glasgow Coma Scale (GCS) score, American Society of Anesthesiologists (ASA) physical status classification, duration of EVD, type of EVD, number of catheters, frequency of replacing catheter, frequency of sampling cerebrospinal fluid (P<0.05) . Multivariate Logistic regression suggested that duration of EVD, number of catheters, pulmonary infection and frequency of sampling cerebrospinal fluid were independent risk factors causing catheter-related ventricular infection (OR=1.070, 13.236, 6.800, 6.248) . Conclusions The catheter-related ventricular infection can be caused by single factor or the synergistic action of multiple factors. The control of pulmonary infection and the management of blood glucose level are helpful to reduce the infection of EVD related infection. Key words: Risk factors; Neurosurgical procedures; External ventricular drainage; Catheter-related infection

Effects of mild hypothermia in secondary brain injury in patients with severe brain injury

Objective To evaluate the effect of mild hypothermia combined with hypbaric oxygen (HBO) treatment on secondary brain injury in patients with severe craniocerebral injury. Methods A prospective study was conducted in this study. Forty-two patients with severe craniocerebral injury admitted to hospital within 8 hours were randomly divided into sub-hypothermia combined with HBO treatment group and conventional HBO control group, 21 cases in either group. Cerebral hemorrhage and brain edema were calculated by reviewed head CT on the 1st day, 15th day and 30th day after injury. GCS (Glasgow Coma Scale) score was calculated at the same time. The number of cases of cerebral infarction was counted in the two groups. GOS (Glasgow Outcome Score) prognosis was scored for both groups of patients six months after injury. Two groups of sample rates were compared using a chi-square test with continuous correction, The intergroup comparisons were analyzed by independent sample t test by using SPSS version 13.0 software.Differences were considered statistically significant if P<0.05. Results (1) The amount of cerebral hemorrhage and edema in the treatment group were significantly lower than those in the control group on the 15th day and 30th day after injury [(21.71±4.3)vs.(26.33±5.23); (14.33±1.93)vs.(16.86±2.86), P<0.05]. (2) The GCS score of the treatment group was higher than that of the control group on the 15th day and 30th day after injury[ (4.62±0.49) vs.(2.49±0.56); (9.76±1.37)vs.(8.57±0.92), P<0.05]; (3) There were 2 cases of traumatic cerebral infarction in the treatment group and 9 cases in the control group (χ2=4.434, P=0.035). The GOS score in the treatment group was higher than that in the control group six months after injury[(4.29±0.84)vs.(3.38±0.74), P=0.001]. Conclusions Mild hypothermia combined with hyperbaric oxygen treatment can reduce the secondary brain injury and improve the prognosis of patients with severe craniocerebral injury. It is worth further study, the mechanism of hypothermia remains to be further studied. Key words: Mild hypothermia; Hyperbaric oxygen; Severe craniocerebral injury; Secondary brain injury; Temperature management; Cerebral infarction; Glasgow Coma Scale; Glasgow Outcome Score

Clinically Meaningful Change Using the Coma Near Coma Scale

Clinically Meaningful Change Using the Coma Near Coma Scale

Clinical effects of damage control surgery in treatment of severe craniocerebral injury combined with multiple extremity fractures

Objective To investigate the effects of damage control surgery (DCS) in the treatment of severe craniocerebral injury patients combined with multiple extremity fractures. Methods The clinical data of 128 patients with severe craniocerebral injury[Glasgow coma scale (GCS) scored 3-8] combined with multiple extremity fractures admitted from May 2011 to August 2015 were retrospectively analyzed by case-control study. There were 81 males and 47 females, with an average age of 37.3 years (range, 19-77 years). The patients were treated with intracranial pressure monitoring in addition to the common administration. The patients were subdivided into two groups: 87 patients treated with DCS concept as damage control group and 41 patients treated with non-DCS routine concept as control group. The DCS group received craniotomy and fracture fixation operation in stage I with selective operation of open reduction and internal fixation. The control group received craniotomy and open reduction and internal fixation in stage I. The postoperative intracranial pressure, operation duration, intraoperative blood loss, hospital stay and prognosis [Glasgow outcome scale (GOS)]were analyzed statistically. Results No intracranial infection was found in all patients during the treatment process. In damage control group, the postoperative intracranial pressure was normal in 44 cases (51%), which was significantly better than that in control group [8 cases (20%)](P<0.05). In damage control group, operation duration [(150.1±12.4)minutes], intraoperative blood loss[(270.6±15.3)ml], and hospital stay [(29.7±9.3)days] were significantly shortened compared with control group, whose operation duration, intraoperative blood loss and hospital stay were (270.6±9.8)minutes, (460.2±17.5)ml, and (34.4±6.2)days, respectively (P<0.05). The GOS rating of damage control group (70%) was notably higher than that in control group (42%) (P<0.05). Conclusion For severe craniocerebral injury patients combined with multiple extremity fractures, the application of DCS contri-butes to control of postoperative intracranial pressure, which can also shorten the duration of hospitalization and improve prognosis. Key words: Craniocerebral injury; Fractures, bone; Decompressive craniectomy; Damage control surgery

Combination effects of invasive intracranial pressure and transcranial Doppler monitoring in treatment of posttraumatic acute diffuse brain swelling

Objective To investigate the combined effects of invasive intracranial pressure and transcranial Doppler (TCD) monitoring in the treatment for posttraumatic acute diffuse brain swelling (PADBS). Methods The clinical data of 120 patients with PADBS admitted from January 2014 to January 2016 were retrospectively analyzed by case-control study. There were 88 males and 32 females, aged 19-70 years (mean, 43.6 years). Patients were divided into three groups based on whether they had accepted invasive intracranial pressure and TCD: Group A (37 cases) with neither invasive intracranial pressure nor TCD, Group B (40 cases) with invasive intracranial pressure only, and Group C (43 cases) with both intracranial pressure and TCD. The hospitalization time in ICU, better prognosis [Glasgow outcome scale (GOS) scored 4-5] at 12 months after injury, Barthel index (BI), and mini-mental status examination (MMSE), mydriasis rate, and decreased values of Glasgow coma scale (GCS) were compared among three groups. Results (1) The ICU length of stay in the Groups of A, B and C was respective (9.6±6.8)days, (9.2±5.4)days and (8.9±5.7)days (P>0.05). The ratio of better prognosis in the Groups of A, B and C was respective 46%(17/37), 65%(26/40) and 72%(31/43), showing a better result in Groups B and C than Group A (P 0.05). The BI in the Groups of A, B and C was respective (51.0±36.7)points, (58.0±35.7)points and (70.2±34.6)points, while the MMSE was respective(17.3±12.5)points, (18.8±12.0)points and (21.2±11.4)points. Both BI and MMSE in Groups B and C were higher than those in Group A (P 0.05). The decreased value of GCS from admission to initiation of operation in Groups A, B and C was (1.4±1.3)points, (0.7±0.5)points and (0.6±0.4)points respectively, showing a larger decrease in Group A than Groups B and C (P 0.05). Conclusion Application of invasive intracranial pressure and TCD monitoring can present a timely and precise condition changes, improve the better prognosis rate, daily activity abilities and cognitive function, indicating that it has protective effects on the brain function. Key words: Brain injuries; Intracranial pressure; Prognosis

Cerebral protective effect of edaravone combined with mild hypothermia in patients with severe craniocerebral injury

Objective To explore the cerebral protective effect of edaravone combined with mild hypothermia in patients with severe craniocerebral injury. Methods 64 patients with severe craniocerebral injury were divided into control groups(n=21), mild hypothermia groups(n=22) and combination groups(n=21) according to the random number table method.All patients were treated with symptomatic supportive therapy and surgical decompression, and the patients in the mild hypothermia group accepted physical cooling and drugs to maintain a low body temperature, and the patients in the combination group accepted edaravone 30mg on the basis of the mild hypothermia group, 1 time every 12 hours, and the course of treatment was lasted for two weeks.The Glasgow coma score(GCS), the degree of brain edema and the Glasgow prognostic score(GOS) were observed in the three groups. Results The GCS scores of the mild hypothermia group and combination group at 7d after admission were (9.54±1.26)points and (10.15±1.56)points, respectively, which were higher than (7.58±1.12)points of the control group, the differences were statistically significant(t=7.867, 12.232, all P<0.05), and the GCS score of the combination group was higher than that of the mild hypothermia group(t=7.986, P<0.05). The GCS scores of the mild hypothermia group and combination group were (12.21±1.47)points and (12.35±1.12)points at 14d after admission, which were higher than (10.28±2.28)points of the control group, the differences were statistically significant(t=8.823, 9.066, all P<0.05). The proportions of mild edema patients in the mild hypothermia group and combination group were 69.09%, 71.43%, respectively, which were higher than 19.05% of the control group, the differences were statistically significant(χ2=9.019, 7.563, all P<0.05). The GOS scores of the mild hypothermia group and combination group at discharge were (4.15±0.51)points and (4.51±0.37)points, respectively, which were higher than (3.69±0.61)points of the control group, the differences were statistically significant(t=5.328, 6.228, all P<0.05), and the GOS score of the combination group was higher than that of the mild hypothermia group(t=4.251, P<0.05). Conclusion The curative effect of edaravone combined with mild hypothermia in the treatment of patients with severe craniocerebral injury is significantly better than conventional therapy and mild hypothermia treatment, and it is conducive to promote the recovery of the nerve function. Key words: Craniocerebral trauma; Hypothermia, induced; Edaravone; Glasgow coma scale

穿孔性腹膜炎によるAeromonas hydrophila敗血症の1例(A case of Aeromonas hydrophila sepsis with perforation peritonitis)

要旨症例は77歳男性で，胃癌，S状結腸癌，前立腺癌に対する手術歴を認め，腸閉塞を複数回発症した既往があった。嘔気・嘔吐と腹痛を主訴に外来受診となり，画像所見より腸閉塞と診断され入院となった。イレウス管を挿入したが，減圧効果は不十分で状態は改善しなかった。第6病日，急に腹痛と腹膜刺激症状が出現し，CTで腹腔内遊離ガスと腹水を認め，穿孔性腹膜炎と診断した。緊急手術を行い，腹腔内には独特の腐敗臭を伴う緑黄色腹水が多量にあり，Treitzから50cm肛門側の空腸に径5mm程の穿孔部位を認めた。また，回盲部より80cm口側の回腸が癒着により閉塞しており，腹腔内を洗浄後に回腸の閉塞を解除し，穿孔部位で双孔式空腸ストマを造設して手術を終了した。術後は敗血症性ショック，播種性血管内凝固症候群（以下DIC）を発症したが，抗菌薬とリコンビナントトロンボモジュリンの投与，polymyxin–B direct hemoperfusionの使用による集中治療により救命し得た。腹水および血液の培養よりAeromonas hydrophila （以下A. hydrophila）が検出され，A. hydrophila敗血症により重症化したと判断した。A. hydrophila敗血症は急激な経過をたどって重篤化すると報告されている。本邦での穿孔性腹膜炎によるA. hydrophila敗血症は稀であるため，文献的考察を加え報告する。

Factors influencing outcome in head injury patients with glasgow coma scale

Background: Over the years in the emergency department, it has been generally observed that the overall outcome in severe head injury patients is very poor. Hence, a study was conducted in traumatic brain injury patients with a Glasgow Coma Scale (GCS) <8, in which various factors that affect outcome in severe head injury patients were analyzed. Objective: The objective of the study was to understand the various factors influencing outcome in patients with severe head injury (GCS ≤8). Subjects and Methods: This was a prospective study, conducted on 350 consecutive acute severe head injury patients with a GCS ≤8. Thirteen independent factors expected to affect prognosis of severe head injury patients were analyzed and studied. Multivariate analysis was used to include adjustment for prognostic variables. Positive predictive value and strong association of the data were analyzed using cumulative percentage, Chi-square test, and cross-tabulation. Results: From the study, it was observed that male population, older age group patients, low GCS on arrival, train accidents, increased time interval, poor motor response, sluggish or absent pupillary reaction to light, absence of dolls eye movement, presence of comorbidities and other severe traumatic injury of major organs, poor glycemic status, and altered coagulation profile were associated with poor outcome in patients. Conclusions: A keen evaluation of patient profile before taking definitive management decisions is recommended, so as to improve the outcome in severe head injury patients. This is because, there are certain factors such as glycemic statuses of the patient, hemoglobin level, and coagulation profile that are modifiable, and if identified and corrected early, could improve the prognosis of the patients to a large extent.

Should We Look for Delayed Traumatic Intracranial Hemorrhage in Patients on Anticoagulants

Mild traumatic brain injury (TBI) is frequently defined as the combination of a Glasgow Coma Scale (GCS) score ≥13, loss of consciousness for <30

Incidence of critical illness-related corticosteroid insufficiency after severe traumatic brain injury and its correlations with prognosis

Objective To observe the incidence of critical illness-related corticosteroid insufficiency (CIRCI) after severe traumatic brain injury (sTBI) and investigate the relationship between CIRCI and prognosis. Methods This prospective cohort study enrolled 89 sTBI patients (68 males and 21 females; at age range of 15-80 years) hospitalized within 24 hours after sTBI from June 2014 to December 2015. The Glasgow coma scale (GCS) was ≤8 points. The causes of injury included extensive contusion of brain (44 cases), subdural hematoma (21 cases), epidural hematoma (11 cases), primary brain stem injury (8 cases) and diffuse axonal injury (5 cases). Adrenocorticotropic hormone (ACTH) stimulation tests were done within 36 hours after sTBI to identify CIRCI patients. The patients were divided into CIRCI group (50 cases) and non-CIRCI group (39 cases). Moreover, the patients were categorized into survival group (62 cases) and death group (27 cases) based on survival status. The GCS score, mechanical ventilation time, cerebral hernia, survival time and mortality within 28 days were observed in two groups. Results The incidence of CIRCI in sTBI patients was as high as 56% (50/89). Compared with the non-CIRCI group, the CIRCI group had lower GCS [(5.3±1.7)points vs. (6.1±1.4)points, P<0.05], and sTBI patients with CIRCI were mechanically ventilated for a longer period of time [(9.9±2.8)days vs. (7.5±1.6)days, P<0.05]. In comparison with non-CIRCI patients, the incidence of brain herniation in sTBI patients with CIRCI was higher (58% vs. 21%, P<0.01). The total fatality rate within 28 days was 30% (27/89). The survival time of CIRCI group was significantly shorter than that of non-CIRCI group (P<0.05). The fatality rate in the CIRCI group was significantly higher than that of the non-CIRCI group [40% (20/50) vs. 18% (7/39), P<0.05]. The incidence of CIRCI in death group was significantly higher than that of the survival group [74% (20/27) vs. 48% (30/62), P<0.05]. Conclusions The incidence of CIRCI in STBI patients is high. The sTBI patients with CIRCI has significantly higher incidence of brain hernia, longer mechanical ventilation time, higher 28-day mortality and shorter survival time compared with non-CIRCI patients. Key words: Brain injuries; Adrenocorticotropic hormone; Prognosis

Postoperative monitoring of body temperature in patients with brain trauma: a prospective multicenter study

Objective To investigate the relationship of brain temperature (intra-ventricle, brain parenchyma, or subdural space) to axillary temperature, rectal temperature and bladder temperature in postoperative patients with brain trauma, and to explore the prognosis value of the brain temperature through a multicenter prospective observational study. Methods A total of 83 patients with brain trauma at 11 hospitals were enrolled to this study from March 2016 to December 2016. The data including patients' brain temperatures, axillary temperatures, rectal temperatures and bladder temperatures were hourly documented postoperatively until withdrawal of monitoring device of brain temperatures. The changes of the values were then further analyzed. Results Compared with the axillary temperature, the subdural temperature difference [0.10(-0.40, 0.40)℃] was less than intraventricular temperature difference [0.30(-0.20, 0.90)℃], which was less than parenchymal temperature difference [0.60(0.20, 1.00)℃](both P<0.05). Compared with rectal temperature and bladder temperature, the subdural temperature difference [-0.20(-0.40, 0.00)℃, -0.10(-0.30, 0.00)℃, respectively] was less than parenchymal temperature difference [0.10(-0.10, 0.20)℃, 0.10(0.00, 0.20)℃, respectively], which was less than intraventricular temperature difference [0.20(0.10, 0.30)℃, 0.20(0.10, 0.30)℃, respectively] (all P<0.05). No matter whether hypothermia treatment was administered, the difference between brain temperature and axillary temperature (ΔTBr-Ax) was larger than that between brain temperature and rectal temperature (ΔTBr-Re) and that between brain temperature and bladder temperature (ΔTBr-Bl) (both P<0.05). When brain temperature was higher than 38 ℃, ΔTBr-Ax was larger than ΔTBr-Re , which was larger than ΔTBr-Bl (both P<0.05). When brain temperature was less than or equal to 38 ℃, ΔTBr-Ax was larger than ΔTBr-Bl, which was larger than ΔTBr-Re (both P<0.05). When the fluctuation of brain temperature within 12 hours post operation was more than 1 ℃, the preoperative Glasgow coma scale (GCS) and the extended Glasgow outcome scale(GOS-E) at discharge were significantly lower compared with those of cases whose brain temperature fluctuation was less than or equal to 1 ℃ (both P<0.05). Conclusions For patients with brain trauma, brain temperature monitoring seems to have a very significant clinical value. When monitoring of brain temperature is not available, the bladder temperature might serve as the best reflection of brain temperature. Key words: Craniocerebral trauma; Body temperature; Multicenter study; Prospective studies

A controlled, multi-center, randomized study of efficacy and safety of troxerutin and cerebroprotein hydrolysate injection for traumatic brain injury

Objective To evaluate the treatment efficacy and safety of troxerutin and cerebroprotein hydrolysate injection(TCHI) in patients with traumatic brain injury. Methods A total of 360 patients with traumatic brain injury were admitted to neurosurgery departments at 10 medical centers (mainly led by Beijing Hospital of Health Ministry) and enrolled into this prospective, multi-center, placebo-controlled, clinical trial from June 2013 to July 2014. Through stratified random sampling, patients were randomized into the TCHI (n=240) group and placebo group (n=120). TCHI(40 mg/ml, 2ml/d, iv) or placebo had been intravenously administered for 14 days starting from patient admission. The parameters were compared between the two groups that included Glasgow coma scale (GCS), Glasgow outcome scale (GOS), level of consciousness, language and motor functions, Karnofsky performance status scale (KPS) and incidence rate of adverse events. Results The study was successfully conducted in 321 out of the 360 cases, which included 213 patients in the TCHI group and 108 patients in the placebo group. The treatment lasted 14 days in both groups. The GCS in TCHI group (14.1±2.0) was significantly higher than that in placebo group (13.4±2.3) (P=0.007), and the ratio of consciousness in TCHI group was remarkably higher than that in placebo group (81.8% vs. 70.0%) (P=0.036). At the 30-day follow-up, the rate of good outcomes assessed by GOS (82.3% vs. 58.1%), rate of normal verbal functional (86.1% vs 61.9%), rate of normal function in upper/lower limb (88.9%/90.4% vs. 78.1%/81.9%) and KPS score(91.3 vs. 89.1) (P<0.05). No serious adverse effects were noted in either group. Conclusion TCHI could be helpful for shortening the coma period and improving the patient's life quality as well as long-term outcome. Key words: Craniocerebral trauma; Multicenter study; Randomized controlled trial; Troxerutin and cerebroprotein hydrolysate injection

Combined monitoring of intracranial pressure and bispectral index in patients with severe craniocerebral trauma after operation

Objective To investigate the value of bispectral index and intracranial pressure monitoring in evaluation of postoperative consciousness and short-term prognosis in patients with severe traumatic brain injury. Methods A simple random sampling method was used in 30 cases of brain trauma coma patients in the People′s Hospital of Northern Jiangsu Province from January 2014 to December 2014. Glasgow coma scale(GCS) were evaluated at intervals of 8 hours, GCS were recorded for 3 days after surgery, The bispectral index value and intracranial pressure value are recorded at the same time. According to GCS, the patients were divided into two groups, group A (3≤GCS≤5) and group B(5<GCS≤8). The 21-days natural survival rate was counted. The Kaplan-Meier Method and Log-rank test were used to analyze the relationship between Bispectral index and intracranial pressure. Results The bispectral index value of group A was 45.3±3.8, the intracranial pressure value of group A was (18.6±2.8) mmHg, The bispectral index value of group B was 32.2±8.2, the intracranial pressure value of group B was (33.4±4.6) mmHg. The 21-days survival rate of group A was 55%, and 21-days survival rate of group B was 30%. The Spearman rank correlation method was used to analyze the values. Bispectral index value was positively correlated with coma degree after operation in patients with severe traumatic brain injury, and was negatively correlated with intracranial pressure value (r=0.532, P<0.05; r=0.521, P<0.05). The more severer the patient′s craniocerebral injury, the more severer the condition, the higher the intracranial pressure, the lower the bispectral index value, the worse the prognosis is. Conclusion Combined monitoring of bispectral index and intracranial pressure has high application value in evaluating the coma degree and prognosis of patients with severe craniocerebral injury after operation. Key words: Craniocerebral trauma; Intracranial pressure; Prognosis; Bispectral index; Monitoring

The determination of brain death in coma children with Glasgow coma scale score 3

Objective To summarize the clinical features and technical key points on brain death during decision-made process in children with suspected brain death. Methods Twenty-four coma children with Glasgow coma scale score 3 and no spontaneous respiration were collected from May 2015 to February 2017 in Beijing Children′s Hospital, Capital Medical University to make the brain death determination.All children received at least one confirmatory test.According to the Chinese standards for determining brain death (pediatric), all patients were divided into brain death group and non-compliance group.The clinical features were analyzed.The sensitivity, specificity, false positive rate and false negative rate of electroencephalogram (EEG), short latency somatosensory evoked potential (SLSEP) and transcranial Doppler sonography (TCD) were calculated. Results Among these 24 cases, there were 16 males and 8 females, aged 5.6 (2.0, 8.8) years old.Ten cases met the criteria of brain death.Twelve (50%, 12/24 cases) cases received autonomic breathing test.A total of 25 tests were conducted, of which 21 were successful.The completion rates of EEG, TCD and SLSEP were 100.0% (24/24 cases), 83.3% (20/24 cases) and 54.2% (13/24 cases), respectively.EEG had the highest sensitivity (100%) and specificity (79%). SLSEP had good sensitivity (100%), but the specificity was only 40%.The combination of EEG with SLSEP had the highest specificity and sensitivity, both of which were 100%, and the false positive rate and false negative rate were 0. Conclusions The key to determine brain death successfully is to make adequate preparations, to receive formal training and to apply standard operation.In the determination of brain death in children, EEG has a good sensitivity and specificity in single confirmation test, which is the priority item.The combination of EEG with SLSEP is the most advantageous. Key words: Glasgow coma scale; Coma; Child; Brain death