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Resuscitation with pressors after traumatic brain injury.
J Am Coll Surg. 2005 Oct; 201(4):536-45.JA

Abstract

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 CO(2) 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 PO(2)s 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 O(2) 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 O(2) 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.

Authors+Show Affiliations

Dewitt-Daughtry Family Department of Surgery, Division of Trauma, University of Miami Miller School of Medicine, Miami, FL 33136, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Research Support, N.I.H., Extramural
Research Support, U.S. Gov't, Non-P.H.S.
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

16183491

Citation

Feinstein, Ara J., et al. "Resuscitation With Pressors After Traumatic Brain Injury." Journal of the American College of Surgeons, vol. 201, no. 4, 2005, pp. 536-45.
Feinstein AJ, Patel MB, Sanui M, et al. Resuscitation with pressors after traumatic brain injury. J Am Coll Surg. 2005;201(4):536-45.
Feinstein, A. J., Patel, M. B., Sanui, M., Cohn, S. M., Majetschak, M., & Proctor, K. G. (2005). Resuscitation with pressors after traumatic brain injury. Journal of the American College of Surgeons, 201(4), 536-45.
Feinstein AJ, et al. Resuscitation With Pressors After Traumatic Brain Injury. J Am Coll Surg. 2005;201(4):536-45. PubMed PMID: 16183491.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Resuscitation with pressors after traumatic brain injury. AU - Feinstein,Ara J, AU - Patel,Mayur B, AU - Sanui,Masamitsu, AU - Cohn,Stephen M, AU - Majetschak,Matthias, AU - Proctor,Kenneth G, PY - 2005/03/15/received PY - 2005/04/27/revised PY - 2005/05/20/accepted PY - 2005/9/27/pubmed PY - 2005/11/11/medline PY - 2005/9/27/entrez SP - 536 EP - 45 JF - Journal of the American College of Surgeons JO - J Am Coll Surg VL - 201 IS - 4 N2 - 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 CO(2) 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 PO(2)s 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 O(2) 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 O(2) 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. SN - 1072-7515 UR - https://www.unboundmedicine.com/medline/citation/16183491/Resuscitation_with_pressors_after_traumatic_brain_injury_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1072-7515(05)00663-0 DB - PRIME DP - Unbound Medicine ER -