Controlled normothermia in critically ill patients with traumatic brain injury

A.V. Tsarev

Abstract


Background. Hyperthermia causes cerebral dama­ge by three mechanisms: cellular, local and systemic. The aim of this research was to study the effectiveness of controlled normothermia in a complex of intensive care in patients with traumatic brain injury (TBI) complicated by the development of hyperthermia of central origin refractory to pharmacological therapy, assessing its effect on the rate of neurologic recovery and the level of mortality. Materials and methods. Sixty patients (mean age 41.05 ± 12.90 years) with a diagnosis of severe TBI, who were treated in the trauma intensive care unit of I.I. Mechnikov Dnipropetrovsk Regional Clinical Hospital. Patients were divided into 4 groups. Group I (n = 15) — controlled normothermia using Blanketrol II (CSZ, USA) in patients with a fever of 38.3–39.5 °C, to achieve the target body temperature — 37 °C; group II (n = 15) — induction of cooling by 4 °C infusion of Ringer’s lactate solution at a dose of 20–23 ml/kg was carried out, followed by maintenance of controlled normothermia with Blanketrol II, in patients with a temperature of ≥ 39.5 °C, to achieve the target body temperature — 37 °C; group III (n = 15) — patients with hyperthermia of 38.3–39.5 °C, with standard intensive care; group IV (n = 15) — patients with hyperthermia ≥ 39.5 °C, with standard intensive care. All patients were evaluated the dynamics of neurological status on the Glasgow Coma Scale (GCS), the duration of the mechanical ventilation of the lungs (MVL). The outcomes of the previous TBI were determined on the basis of the Cerebral Performance Categories (CPC) scale on the 28th day of the study. Results. In group I (38.98 ± 0.28 °C) and group III (38.94 ± 0.27 °C), there were no significant differences in the level of initial hyperthermia. There was a tendency for a deeper neurological deficit initially in group I compared with group III of patients: 6.26 ± 0.77 points and 6.60 ± 0.71 points on the GCS, respectively. On the contrary, the group II of patients had significantly more deeper level of neurological deficit on the baseline (GCS 5.33 ± 0.47 points, p < 0.05), compared with patients of group IV (GCS 5.66 ± 0.47 points). When analyzing the duration of MVL, there were no significant differences between group I (10.86 ± 9.49 days) and group III (10.26 ± 4.13 days). The tendency of longer MVL in the group IV (25.53 ± 8.09 days) was revealed in comparison with the patients of the group II (18.86 ± 8.39 days).The level of mortality in the group I was 20 %, in group III — 13.3 %, in group II — 33.3 %, in group IV — 46.7 %, but the diffe­rences were also not significant. When analyzing the neurological outcome on the 28th day using the CPC scale, there was a tendency to improve outcomes in group I (2.20 ± 1.27 points) as compared to patients of group III (2.86 ± 1.08 points). On the contrary, there was a significant improvement in neurological outcomes in group II (2.60 ± 1.40 points) compared with group IV patients (3.66 ± 1.49 points). We did not detect clinically significant side effects of the proposed variants of controlled normothermia. Conclusions. The proposed method of controlled normothermia creates more favourable conditions for a more complete restoration of disturbed neurological functions after severe traumatic brain injury.

Keywords


craniocerebral trauma; hyperthermia; fever; controlled normothermia; intensive therapy

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DOI: https://doi.org/10.22141/2224-0586.3.82.2017.102326

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