Clinical practice guidelines in severe traumatic brain injury in Taiwan
ABSTRACT Severe TBIs are major causes of disability and death in accidents. The Brain Trauma Foundation supported the first edition of the Guidelines for the Management of Severe Traumatic Brain Injury in 1995 and revised it in 2000. The recommendations in these guidelines are well accepted in the world. There are still some different views on trauma mechanisms, pathogenesis, and managements in different areas. Individualized guidelines for different countries would be necessary, and Taiwan is no exception.
In November 2005, we organized the severe TBI guidelines committee and selected 9 topics, including ER treatment, ICP monitoring, CPP, fluid therapy, use of sedatives, nutrition, intracranial hypertension, seizure prophylaxis, and second-tier therapy. We have since searched key questions in these topics on Medline. References are classified into 8 levels of evidence: 1++, 1+, 1-, 2++, 2+, 2-, 3, and 4 based on the criteria of the SIGN.
Recommendations are formed and graded as A, B, C, and D. Grade A means that at least one piece of evidence is rated as 1++, whereas grade B means inclusion of studies rated as 2++. Grade C means inclusion of references rated as 2+, and grade D means levels of evidence rated as 3 or 4. Overall, 42 recommendations are formed. Three of these are rated as grade A, 13 as grade B, 21 as grade C, and 5 as grade D.
We have completed the first evidence-based, clinical practice guidelines for severe TBIs. It is hoped that the guidelines will provide concepts and recommendations to promote the quality of care for severe TBIs in Taiwan.
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ABSTRACT: Das schwere Schädel-Hirn-Trauma (SHT) gehört zu den häufigsten Todesursachen bei jungen Erwachsenen. Beim schweren SHT folgt der primären Verletzung in der Regel eine ausgeprägte pathophysiologische Kaskade, die Sekundärschäden anrichtet und für eine Vielzahl der Todesfälle verantwortlich ist. Ziel der intensivmedizinischen Therapie nach SHT ist es u. a., die Ausprägung und die damit einhergehenden Komplikationen zu kontrollieren. Von besonderer Bedeutung sind dabei das strikte Vermeiden von Hypoxämie, arterieller Hypotension, intrakranieller Hypertension, Hyperthermie, Hyperglykämie, Hypoglykämie und thrombembolischen Ereignissen. Eine weitere Möglichkeit, den Verlauf bzw. das Ausmaß eines SHT günstig zu beeinflussen, ergibt sich aus dem bis dato vergleichsweise wenig beachteten intensivmedizinischen Aspekt der Ernährung von Intensivpatienten nach SHT. Innerhalb von 24 h sollte bei diesen Patienten mit der Ernährung begonnen werden. Generell sollte, wenn möglich, einer enteralen Ernährung der Vorzug gegeben werden. Die volle enterale Verabreichung des errechneten Energiebedarfs vom ersten Tag nach Trauma, wenn möglich, kann dazu beitragen, die Infektions- und allgemeine Komplikationsrate signifikant zu senken. In der vorliegenden Arbeit soll der Stellenwert der Ernährung bei der Therapie des SHT betrachtet werden.Der Anaesthesist 08/2012; 61(8). DOI:10.1007/s00101-012-2061-x
Article: Brain abscess: Current management[Show abstract] [Hide abstract]
ABSTRACT: Brain abscess (BA) is defined as a focal infection within the brain parenchyma, which starts as a localized area of cerebritis, which is subsequently converted into a collection of pus within a well-vascularized capsule. BA must be differentiated from parameningeal infections, including epidural abscess and subdural empyema. The BA is a challenge for the neurosurgeon because it is needed good clinical, pharmacological, and surgical skills for providing good clinical outcomes and prognosis to BA patients. Considered an infrequent brain infection, BA could be a devastator entity that easily left the patient into dead. The aim of this work is to review the current concepts regarding epidemiology, pathophysiology, etiology, clinical presentation, diagnosis, and management of BA.08/2013; 4(Suppl 1):S67-S81. DOI:10.4103/0976-3147.116472
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ABSTRACT: Compared to adults, children and adolescents are at greater risk for traumatic brain injury (TBI), with increased severity and prolonged recovery when compared to adults. It is a challenge to provide care for those children who are at risk for complications of TBI under health care resource constraints. To investigate hospitalization among children with intracranial injuries in terms of incidence and factors related to length of stay (LOS) and medical cost. Data from the National Health Insurance Research Database from 2007-2009 were used. In total 8632 children aged <=18 years with acute traumatic intracranial injuries caused by accidents were discharged from hospitals in Taiwan. The associations between patient and hospital covariates (e.g., age, gender, accreditation level of hospital, surgical intervention, and number of comorbid conditions) and log-transferred hospitalization cost and length of stay (LOS) were examined with multivariable regression analysis and mediation analyses. The incidence rate of hospitalization for acute intracranial injury was 63.3/100,000 per year. Motor vehicle crashes and falls accounted for 63.5% and 23.8% of intracranial injuries, respectively. The mean LOS for children was 5.0 days (median, 3 days), incurring a mean direct medical cost of $US 916.70 (median, $356.2). Boy sustained more injury (64.1%) and greater medicals cost ($965) occurred in boys. Patients with subarachnoid subdural and extradural haemorrhage tended to have a longer LOS and incur greater medical costs. Surgical intervention and type of healthcare institution were also significant predictors for medical costs. Additionally, LOS was the dominant mediator for the relationship between predictor and medical cost. Acute intracranial injuries among children incur a substantial health care burden. Therefore, health authorities need to optimally allocate medical resources in care.Injury 09/2013; DOI:10.1016/j.injury.2013.09.031