Excerpt
Management of patients suffering from acute neurological injury, such as traumatic brain injury (TBI) or stroke, mandates high-quality care throughout the whole trajectory, including adequate triage for multi-casualty trauma [
1], care path bundles, and early revascularization for stroke [
2], antifibrinolytic agents in specific subgroups of TBI patients [
3], and prevention as well as treatment of associated systemic effects, such as electrolyte disturbances or alterations in kidney function [
4]. The benefits and safety of early mobilization in the intensive care unit (ICU) are well established. However, in a sub-study of 200 patients from the Surgical ICU Optimal Mobilization Score (SOMS) trial [
5], patients with an admission Glasgow Coma Scale (GCS) < 8 tended to be mobilized later, even while the benefits of mobilization were also present in this subgroup with severe neurological impairment. The management of respiratory failure can be challenging in patients with acute brain injury, especially when there is concern about increased intracranial pressure (ICP) or secondary brain injury. Nevertheless, the literature on lung-protective ventilation in these patients suggests that low tidal volume, high PEEP, and even rescue therapies, such as prone ventilation, could be applied here, with caution and close monitoring [
6]. Neuroprotection is mainly driven by balancing substrate and oxygen delivery and demand to the brain [
7]. Alternative energy substrates, such as lactate, or ketone bodies, may be potential future options to boost cerebral energy metabolism [
8], but further prospective trials are needed to demonstrate their theoretical benefits. Impaired cerebral blood flow (CBF) plays an important role in secondary brain injury. Brain ultrasonography is a noninvasive method that allows to assess structural brain abnormalities, as well as a valid option to assess CBF-changes [
9]. This technique can be taught easily and is increasingly being used in the ICU and the emergency department. The large prospective observational CENTER-TBI study [
10] has demonstrated striking regional and national variations in TBI management across different regions and countries. There is wide agreement amongst experts, supported by experimental work, cohort studies, and clinical expertise that a neuromonitoring-based treatment approach allows for a rational and physiology-based management in TBI, even while evidence from randomized-controlled trials for improved clinical outcomes through such strategy is currently lacking. The recently published Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) guidelines now provide algorithms for ICP-based adult TBI management [
11]. Using a Delphi-method-based approach, experts recommend 18 interventions as fundamental and 10 treatments not to be used for the treatment of elevated ICP. A comprehensive practical tiered management algorithm was designed, to aid clinicians in their choice on the appropriate therapy. …
