Resuscitation with Pressors after Traumatic Brain Injury - 21/08/11
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Résumé |
Background |
The purpose of the study was to compare initial resuscitation with arginine vasopressin (AVP), phenylephrine (PE), or isotonic crystalloid fluid alone after traumatic brain injury and vasodilatory shock.
Study design |
Anesthetized, ventilated swine (n = 39, 30 ± 2 kg) underwent fluid percussion traumatic brain injury followed by hemorrhage (30 ± 2mL/kg) to a mean arterial pressure < 30mmHg, then were randomized to 1 of 5 groups to maintain mean arterial pressure > 60mmHg for 30 to 60minutes, then cerebral perfusion pressure > 60mmHg for 60 to 300minutes, either unlimited crystalloid fluid only (n = 9), arginine vasopressin + fluid (n = 9), phenylephrine + fluid (n = 9), arginine vasopressin only (n = 5), or phenylephrine only (n = 5). Heterologous transfusions were administered if hematocrit was < 13, and mannitol was administered if intracranial pressure was > 20 mmHg. Cerebrovascular reactivity was evaluated with serial CO2 challenges.
Results |
In all groups, physiologic variables were similar at baseline and at the end of shock. On resuscitation, all achieved mean arterial pressure and cerebral perfusion pressure goals. Brain tissue PO2s were similar. With fluid only, more blood and mannitol were required, intracranial pressure and peak inspiratory pressure were higher, and cerebrovascular reactivity was decreased (all p < 0.05 versus pressor + fluid). With either pressor + fluid, cardiac output, heart rate, lactate, and mixed venous O2 saturation were similar to fluid only, but total fluid requirements and urine output were both reduced (p < 0.05). With either pressor only, intracranial pressure remained low, but mixed venous O2 saturation, cardiac output, and urine output were decreased (all p < 0.05 versus other groups).
Conclusions |
To correct vasodilatory shock after traumatic brain injury, a resuscitation strategy that combined either phenylephrine or arginine vasopressin plus crystalloid was superior to either fluid alone or pressor alone.
Le texte complet de cet article est disponible en PDF.Abbreviations and Acronyms : AVP, CPP, ICP, MAP, NS, PbtO2, PE, SvO2, TBI
Plan
Competing Interests Declared: None. Supported by grants #N000140210339, #N000140210035 from the Office of Naval Research, and #T32 GM08749-01 from the NIH-GMS. Dr Feinstein’s current address is Department of Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Dr Cohn’s current address is Department of Surgery, University of Texas Health Science Center, San Antonio, TX. |
Vol 201 - N° 4
P. 536-545 - octobre 2005 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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