Lent/régulier: Mieux pour le crâne ?

Resuscitation speed affects brain injury in a large animal model of traumatic brain injury and shock

Sillesen M et Al. Scand J Trauma Resusc Emerg Med. 2014 Aug 14;22:46

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En matière de remplissage vasculaire,  on s'intéresse souvent à la nature des solutés et aux quantités perfusées. On s'intéresse moins aux vitesses de perfusion. Pourtant cette dernière a son importance. Le travail présenté est intéressant car il rapport qu'outre la nature du soluté importante mais aussi sa vitesse d'administration. Ainsi il semblerait que dans un modèle expérimental de traumatisme crânien l'emploi de solutés cristalloïdes de sérum salé isotonique soit responsable d'une augmentation de l'oedeme cérébal et du volume des lésions intracraniennes quel que soit le régime d'administration. Ce travail retrouve par ailleurs l'intérêt sur la maîtrise de l'oedeème cérébral  de l'apport de fraction coagulantes de manière procédurée par rapport au bolus. Si l'on replace ce document dans le contexte d'isolement et de maintien en survie de nos blessés notamment cranio-cérébraux en état de choc, cela implique une formation spécifique des équipes qui devront par ailleurs pouvoir disposer d'équipements adaptés comme celui_ci (1)

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BACKGROUND:

Optimal fluid resuscitation strategy following combined traumatic brain injury (TBI) and hemorrhagic shock (HS) remain controversial and the effect of resuscitation infusion speed on outcome is not well known. We have previously reported that bolus infusion of fresh frozen plasma (FFP) protects the brain compared with bolus infusion of 0.9% normal saline (NS). We now hypothesize reducing resuscitationinfusion speed through a stepwise infusion speed increment protocol using either FFP or NS would provide neuroprotection compared with a highspeed resuscitation protocol.

METHODS:

23 Yorkshire swine underwent a protocol of computer controlled TBI and 40% hemorrhage. Animals were left in shock (mean arterial pressure of 35 mmHg) for two hours prior to resuscitation with bolus FFP (n = 5, 50 ml/min) or stepwise infusion speed increment FFP (n = 6), bolus NS (n = 5, 165 ml/min) or stepwise infusion speed increment NS (n = 7). Hemodynamic variables over a 6-hour observation phase were recorded. Following euthanasia, brains were harvested and lesion size as well as brain swelling was measured.

RESULTS:

Bolus FFP resuscitation resulted in greater brain swelling (22.36 ± 1.03% vs. 15.58 ± 2.52%, p = 0.04), but similar lesion size compared with stepwise resuscitation. This was associated with a lower cardiac output (CO: 4.81 ± 1.50 l/min vs. 5.45 ± 1.14 l/min, p = 0.03). In the NS groups, bolus infusion resulted in both increased brain swelling (37.24 ± 1.63% vs. 26.74 ± 1.33%, p = 0.05) as well as lesion size (3285.44 ± 130.81 mm(3) vs. 2509.41 ± 297.44 mm3, p = 0.04). This was also associated with decreased cardiac output (NS: 4.37 ± 0.12 l/min vs. 6.35 ± 0.10 l/min, p < 0.01).

CONCLUSIONS:

In this clinically relevant model of combined TBI and HS, stepwise resuscitation protected the brain compared with bolusresuscitation.