Our Work

Protocols

VGH SAH Protocol

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Status Epilepticus Management Protocol

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Severe Traumatic Brain Injury Management

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Publications

Adherence to guidelines for management of cerebral perfusion pressure and outcome in patients who have severe traumatic brain injury

Authors:  Griesdale DE, Ortenwall V, Norena M, Wong H, Sekhon MS, Kolmodin L, Henderson WR, Dodek P

Journal / Year
:  Journal of Critical Care, 2014

Background summary: Maintaining adequate oxygen delivery to the injured brain is paramount in the management of TBI. We conducted a retrospective cohort study of patients with severe traumatic brain injury who underwent invasive intracranial pressure monitoring. We aimed to investigate the adherence to guideline based management for the maintenance of cerebral perfusion pressure targets and its relationship to mortality in our cohort

Results summary: Interestingly, we discovered that the CPP was maintained above the  recommended threshold in the majority of patents (CPP goal 50 to 70 mmHg). There was an associated reduction in mortality if patients were maintained at a CPP > 70 mmHg.

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/25179411

 

Increased blood glucose is related to disturbed cerebrovascular pressure reactivity after traumatic brain injury

Authors: Donnelly J, Czosnyka M, Sudhan N, Varsos G, Nasr N, Jalloh I, Liu X, Dias C, Sekhon MS, Carpenter KL, Menon DK,
Hutchinson PJ, Smielewski P

Journal / Year:  Neurocritical Care, 2014

Background summary: Hyper and hypoglycemia can have adverse effects on the injured brain. Hyperglycemia has been associated with adverse outcome in patients with intracerebral hemorrhage, subarachnoid hemorrhage and TBI. Additionally, hyperglycemia has been associated with infarct expansion in peri-injury neuronal tissue but an underlying mechanism has not been elucidated. Therefore, we investigated the relationship of serum glucose concentration and its effect on cerebrovascular autoregulation post TBI using pressure reactivity index.

Results summary: We demonstrated that serum hyperglycemia is associated with a disturbance in pressure reactivity index / cerebrovascular autoregulation. This finding could explain why infarct size expansion and adverse outcomes are seen in patients with persistent hyperglycemia after cerebral injury.

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/25124103

 

Optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury

Authors: Sekhon MS, Griesdale DE, Robba C, McGlashan N, Needham E, Walland K, Shook AC, Smielewski P, Czosnyka M, Gupta AK, Menon DK

Journal / Year:  Intensive Care Medicine, 2014

Background summary: After TBI, intracranial pressure commonly increases secondary to cerebral edema and space occupying lesions which results in secondary ischemic injury. Invasive ICP monitoring is not universally available and has associated risks, therefore, non-invasive estimation of ICP has garnered interest. Estimation of the optic nerve sheath diameter on ultrasound and magnetic resonance is closely associated with increased ICP, however, procedural expertise and availability limit their widespread use. Therefore, we decided to investigate the relation of ONSD on computed tomography and simuktaneously measured ICP.


Results summary: We found that ONSD measured on CT was significantly correlated with simultaneously measured increased ICP. Specifically, an ONSD > 7mm had a high positive predictive value for an ICP > 20mmHg and an ONSD < 6mm effectively ruled out an ICP > 20mmHg. Additionally, measurement of ONSD on CT was highly reproducible amongst observers. These results need to be confirmed in a prospective study.


Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/25034476 

 

Association between optic nerve sheath diameter and mortality in patients with severe traumatic brain injury

Authors:  Sekhon MS, McBeth P, Zou J, Qiao L, Kolmodin L, Henderson WR, Reynolds S, Griesdale DE

Journal / Year:  Neurocritical Care, 2014

Background summary: Increased intracranial pressure is associated with adverse outcome in patients with TBI. Identification of patients who are at risk for developing increased ICP and necessitating aggressive management is difficult. The optic nerve sheath diameter is associated with increased ICP and adverse outcome on ultrasound. We aimed to confirm with elevated ONSDs on CT.


Results summary: We confirmed a relationship of increased mortality in TBI patients with increased ONSD on CT. Additionally, we found a relationship of increased intracranial hypertension in patients who presented on admission with elevated ONSDs on CT.


Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/24969027

 

Sixty four slice computed tomographic scanner to clear traumatic cervical spine injury: systematic review of the literature

Authors:  Kanji HD, Neitzel A, Sekhon M, McCallum J, Griesdale DE

Journal / Year:  Journal of Critical Care, 2014

Background summary: Clearance of the unconscious trauma patient's cervical spine is difficult. There is controversy as to whether computed tomography is sufficient to clear the cervical spine or whether magnetic resonance imaging is required. We conducted a systematic review of the literature investigating the whether 64 slice CT scanning is comparable to MRI for cervical spine clearance in the unconscious trauma patient.

Results summary:  Data from available studies suggest that 64 slice CT scanning may be sufficient to exclude cervical spine injury in the obtunded trauma patient. A prospective trial of CT scanning vs. MRI is required to conclusively answer this question.


Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/24393410

 

Hypernatremia in patients with severe traumatic brain injury: a systematic review

Authors:  Kolmodin L, Sekhon MS, Henderson WR, Turgeon AF, Griesdale DE

Journal / Year:  Annals of Intensive Care, 2013

Background summary:   Therapeutic hypernatremia is commonly used in TBI patients to manage increased ICP. It is unclear if this is associated with improved outcome. Therefore, we conducted a systematic review investigating the relationship between hypernatremia and mortality in patients with severe TBI

Results summary:  Hypernatremia seemed to be associated with increased mortality, however there was marked between-study heterogeneity and likely confounded by central diabetes insipidus. Prospective studies are required.


Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/24196399

 

Association of hemoglobin concentration and mortality in critically ill patients with severe traumatic  brain injury

Authors:  Sekhon MS, McLean N, Henderson WR, Chittock DR, Griesdale DE

Journal / Year:  Critical Care, 2012

Background summary:   Prevention of secondary ischemic injury of the injured brain post TBI is the cornerstone of its critical care management strategy. Anemia is common post TBI and has been associated with adverse outcome, however, the exact hemoglobin concentration at which the risk of secondary ischemic neuronal injury occurs at is controversial. We aimed to investigate the relationship between mortality and various hemoglobin concentrations in patients with severe traumatic brain injury.

Results summary:  We demonstrated that patients with a mean hemoglobin < 90g/L for the first 7 days of admission had a significantly increased risk of adverse outcome (mortality) during hospitalization. Further study is required to identify the optimal hemoglobin concentration in patients with TBI. 

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/22817913

 

The safety of synthetic colloid in critically ill patients with severe traumatic brain injury

Authors:  Sekhon MS, Dhingra VK, Sekhon IS, Henderson WR, McLean N, Griesdale DE

Journal / Year:  Journal of Critical Care, 2011

Background summary:  Intravenous resuscitation with colloids is associated with risks. Albumin adminstration has been associated with increased mortality and ICP in patients with TBI. We aimed to investigate the relationship between synthetic starch based colloids and mortality in patients with TBI.

Results summary:  We demonstrated the administration of medium sized starch based colloid solutions was not associated with increased mortality or adverse outcomes in patients with severe TBI. However, the emerging significant extra-cranial adverse effects associated with these solutions likely preclude their use in all critically ill patients.

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/21273030

 

Intratentorial surgery is an independent risk factor for respiratory failure and death in patients undergoing intracranial tumor resection

Authors:  Flexman AM, Merriman B, Griesdale DE, Mayson K, Choi PT, Ryerson CJ

Journal / Year:  Journal of Neurosurgical Anesthesiology, 2014

Background summary:  Respiratory failure and death are devastating outcomes in the postoperative period, especially in patients undergoing neurosurgical procedures of the intraftentorial compartment. We wanted to determine the incidence of postoperative respiratory failure and death in the neurosurgical population and determine whether infratentorial procedures are associated with a higher risk compared with supratentorial procedures.

Results summary:  Infratentorial neurosurgery is an independent risk factor for respiratory failure and death in patients undergoing intracranial tumor resection. Mortality is an important contributor to this risk and should be a focus for future research.

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/23933960

 

Intracranial pressure monitors in traumatic brain injury: a systematic review

Authors:  Mendelson AA, Gillis C, Henderson WR, Ronco JJ, Dhingra V, Griesdale DE.

Journal / Year:  Canadian Journal of Neurological Sciences, 2012

Background summary:  Intracranial pressure monitoring is a mainstay in the management of patients with severe traumatic brain injury despite definitive evidence supporting its use. We conducted a systematic review to assess the relationship between clinical outcomes and invasive neuromonitoring in patients with severe TBI.

Results summary:  There was marked heterogeneity in the studies included. Additionally, there is significant confounding by indication when examining this patient population with the sickest and severe TBI patients undergoing neuromonitoring. Further study needs to be conducted to determine which patients will benefit from invasive neuromonitoring,

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/22931696

 

External ventricular drains and mortality in patients with severe traumatic brain injury

Authors:  Griesdale DE, McEwen J, Kurth T, Chittock DR

Journal / Year:  Canadian Journal of Neurological Sciences, 2010

Background summary: External ventricular drains are used as the gold standard of ICP monitoring in TBI patients. Their use had not been evaluated in relation to clinical outcome. Therefore, we conducted a retrospective cohort study evaluating this relationship.

Results summary:  There was a relationship between 28 day mortality and patients with a presenting GCS > 6. Given the retrospective nature of this report, further study is required to identify which patients will benefit most from invasive neuromonitoring.

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/20169772

 

Glucose control and mortality in patients with severe traumatic brain injury

Authors:  Griesdale DE, Tremblay MH, McEwen J, Chittock DR

Journal / Year:  Neurocritical Care, 2009

Background summary: The optimal glucose range in patients with severe traumatic brain injury (TBI) remains unclear. The goal of this study was to examine the association of serum glucose levels on mortality in patients with severe TBI.

Results summary:  Any episode of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) was associated with 3.6-fold increased risk of hospital mortality in patients with severe TBI and thus, should be avoided. Maintaining serum glucose ≤ 10 mmol/l appears to be a reasonable balance to avoid extremes of glucose control, but further studies are needed to determine the optimal glucose range.

Pubmed link:  http://www.ncbi.nlm.nih.gov/pubmed/19636972