IFAD 2013

1. 2013
Philippe G Jorens
Department of Critical Care Medicine
University of Antwerp, Antwerp
University Hospital , Belgium
Fluid strategy in
traumatic brain injury

2. 1. Physio pathogenesis of TBI
 Primary injury
 physical damage to the parenchyma during the insult
 shearing and compression
 Secondary injury
 complex process
 edema
 (Webster’s dictionary)
 an abnormal collection of watery fluid in a bodily tissue or cavity

3. Ropper 2012
ICP and edema determine outcome
The cranium is a fixed vault …
Brain parenchyma = 80 % water:
brain volume is
responsive to changes in water
content
CPP = MAP – ICP

4. Your brain is precious
 Keep it dry …

5. What should we do ?
 Confused … ?
 Confusion …

6. Confused ? (Webster’s)
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected,
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

7. 2. Physio pathogenesis: blood brain
barrier

8. Blood brain barrier
ParadesAndrade et al. 2012

9. What happens in our patients with
TBI ?
 Hypotension (defined as SBP < 90 mm hg)
 MAP < 65 mm Hg ; occurs 73 % during ICU stay (Chesnut et
al. 1993)
 Independent predictor of severe outcome ( Chesnut et al,
1993b): doubling mortality
 Hypovolemia and hypoosmolarity worsen brain edema
 Hypoalbuminemia correlates with worse outcome (Powner et
al;.2011)

10. What happens : autoregulation

11. What should we do ?
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected …
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

12. Original Article
A Trial of Intracranial-Pressure Monitoring in
Traumatic Brain Injury
Randall M. Chesnut, M.D., Nancy Temkin, Ph.D., Nancy Carney, Ph.D., Sureyya
Dikmen, Ph.D., Carlos Rondina, M.D., Walter Videtta, M.D., Gustavo Petroni, M.D.,
Silvia Lujan, M.D., Jim Pridgeon, M.H.A., Jason Barber, M.S., Joan Machamer, M.A.,
Kelley Chaddock, B.A., Juanita M. Celix, M.D., Marianna Cherner, Ph.D., and Terence
Hendrix, B.A.
N Engl J Med
Volume 367(26):2471-2481
December 27, 2012

13. Cumulative Survival Rate According to Study Group.
Chesnut RM et al. N Engl J Med 2012;367:2471-2481

14. What should we do ?
 Aggressive fluid administration
 CVP 8 – 10 mm Hg
 Monitor (PCWP 12 -15 mm Hg)
 Excessive and inappropiate
 Fluid overload and ARDS
 Large amounts of fluids can be administered in most TBI
patients

15. Which fluids should we use ?
 Crystalloid-based fluid strategies are favored
 But evidence in brain injury is limited
 Pragmatic approach to resuscitation …

16. What should we do ?
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected,
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

17. Hyperglycemia is bad …
 Infusion of glucose 5 % bad ?
 Glucose sole energy for brain cells …
 Moro et al. Brain Res 2013 … glucose administration
 Rats:
 neuroprotection in cortex and hippocampus on day 1
 Improved cerebral metabolism …

18. Lactate is bad …
 waste product of anaerobic metabolism …
 But lactate is elegantly used as an alternative fuel in the brain
…
 J Neurotrauma 2013, Epub ahead of print
 Lactate uptake was associated with higher AV difference in glucose
values …
 Hyperosmolar sodium lactate decreases ICP

21. What should we do ?
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected,
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

22. A Comparison of Albumin and Saline for Fluid
Resuscitation in the Intensive Care Unit
The SAFE Study Investigators
N Engl J Med
Volume 350;22:2247-2256
May 27, 2004

23. Kaplan-Meier Estimates of the Probability of Survival
The SAFE Study Investigators, . N Engl J Med
2004;350:2247-2256

24. Original Article
Saline or Albumin for Fluid Resuscitation in
Patients with Traumatic Brain Injury
The SAFE Study Investigators
N Engl J Med
Volume 357(9):874-884
August 30, 2007

25. Kaplan-Meier Estimates of the Probability of Survival
The SAFE Study Investigators. N Engl J Med 2007;357:874-
884

26. Why ?
 Cooper DJ et al. J Neurotrauma 2013,
 n = 321
 164 albumin
 157 saline
 Use of albumin associated with linear increase in mean ICP
…

27. Hypertonic or hyperosmolar solutions
?
 Mannitol
 causes ICP decrease by the elimination of water
 Osm 310-320 mosm/kg
 Compensated by adequate fluid replacement …
 Problem list: cause a reverse osmotic shift, raising brain osmolarity
(Wise et al. 1964)
 HSS
 increasing salt
 expands intravascular volume (Para et al. 2010)
 Improves rheology
 Both improve “inflammation” in animal models of TBI

28. Hypertonic better than mannitol ?
Hooman et al. 2011

29. Hays et al. 2011
The lack of scientific evidence leads to heterogeneous practice patterns
. Hays et al. 2011

30. What should we do ?
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected,
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

31. What should we do ?
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected,
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

32. A. We have not listened to nature …
 Albumin BB

33. B. We have used the wrong endpoints
…
 SAFE:
 evaluation albumin directed to hemodynamic/resuscitation
endpoints , not the posssible benefits of maintaining serum
albumin during ongoing care
 Hyperosmolar agents remove fluid from the remaining
normal brain tissue : little effect on the damaged brain
 Once hyperosmolarity has been attained, it must be
sustained

34. C. Houston, we have a problem …
Albumin 4 %

35. Powner et al. 2011

36. Rohling-Waldstrom et al. 2009
Albumin 4 and 20 %
Albumin 4 and 20 %

37. Hypotonic solutions ? Wright 2012

38. Van Aken et al. 2012
This means: human albumin 4% , gelatine and Hartmann’s solution:
low measured in-vitro osmolality
That no colloids should be used in patients with TBI is not supported by
physiological principlis:
rather … hypo-osmolar/hypotonic solutions should be avoided …

39. D. Two forms of edema …
 Vasogenic edema
 Breakdown BBB
 Along white-matter tracts : spares cortical gray matter
 Contusion, inflammation, subacute phase of cerebral
infarction
 Cytotoxic edema:
 Ischemia: reduction of ATP production
 Cellular swelling
 Hyperacute ischemic infarction
 Gray and white matter

40. E. Quantitative imaging assessment
of the BBB… (Chassidim et al. 2013)

41. Hardware Requirements Scheme
41 |

42. Confused …
 We want to keep the brain dry

43. Confused …
 We want to perfuse the brain

44. What should we do ?
 Confusion:
 a situation in which people are uncertain about what to
do or are unable to understand something clearly
 the feeling that you have when you do not understand
what is happening, what is expected,
 a state or situation in which many things are happening
in a way that is not controlled or orderly
 the act of mistakenly thinking that one person or thing
is another

45. Guidelines ….
 Reinhart et al. Intensive Care Med 2012
 Consensus statement on colloid volume therapy as
interpreted by the respective ESICM task force.
 No colloids should be used in patients with head injury …

46. Recommendations for Fluid Resuscitation in Acutely Ill Patients.
Myburgh JA, Mythen MG. N Engl J Med 2013;369:1243-1251

47. Conclusion
 Large amounts of fluids can be used in TBI
 Colloids should be used with caution or not ?
 Albumin ?
 Avoid hypotonic solutions
 Hypertonic solutions can be used