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- Alex Manara (15 December 2004)
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Reduction in mortality from severe head injury following introduction of a protocol for intensive ca
- Simon P Young (15 December 2004)
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Alex Manara, Consultant in Anaesthesia and Intensive Care Frenchay Hospital, Bristol, UK
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Editor, The importance of maintaining normoglycaemia after brain injury and the potential for hyperglycaemia to further damage an ischaemic brain has been appreciated for some time (1). As a result maintenance of normoglycaemia had become standard neuro-intensive care practice. The blood glucose target in our protocol was no different to that we aimed to achieve before the protocol was introduced. Indeed many of the targets and interventions in the protocol were not new or redefined. The main function of the protocol was to ensure an adequate cerebral perfusion pressure by treating the mean arterial pressure and the intracranial pressure in a standardised and logical stepwise fashion. Dr Young is right to highlight the importance of Van den Berghe’s findings (2) of a reduction in mortality in patients receiving intensive care using a low-tech, low-cost treatment. However this information was neither available to us at the time our protocol was introduced in1997 nor indeed by the end of our study period in 2000. There is therefore no reason why we would have changed our blood glucose target in 1997 and no reason to suspect that we pursued this target any more vigorously after the implementation of our head injury protocol. Alex Manara Bristol, UK 1. Fitch W. Hyperglycaemia and ischaemic brain damage. In Kaufman L. ed. Anaesthesia Review 5, Edinburgh: Churchill Livingstone 1988; 119-30 2. Van den Berghe G, Wouter P, Weekers F, Verwaest C, Bruynincks F, Schetz M, Vlasselaers D, ferdinane P, Lauwers P, Buillon R. Intensive insulin therapy in critically ill patients. New Engl J Med 2001; 345: 1359 -67. Conflict of Interest:None declared |
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Simon P Young
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Editor – Clayton et al report a relative risk reduction in intensive care mortality of nearly 30% from severe head injury with the introduction of protocol-driven management to Frenchay Hospital (1). Adequate cerebral perfusion pressure is the primary goal of this protocol. However I note with interest that the Frenchay protocols also target a blood sugar level of 4-7 mmol.l-1. Van den Berghe et al describe a relative risk reduction in intensive care mortality of 43% with introduction of tight glycaemic control (blood glucose 4.4-6.1 mmol.l-1) in a population of predominantly post cardiac surgery patients in Belgium (2). Interestingly, compared to typical British general intensive care patients, the patient groups in Frenchay and Belgium may be somewhat similar in terms of predominance of single organ failure and lower APACHE II scores. This type of patient may benefit significantly more from tight glycaemic control than general intensive care patients. I would be interested to know the blood glucose target in the period before protocol introduction at Frenchay, and how well targets were actually achieved. It may be that the improved mortality was at least in part a result of the low-tech, low cost adherence to tight glycaemic control. References: 1. Clayton TJ, Nelson RJ, Manara AR. Reduction in mortality from severe head injury following introduction of a protocol for intensive care management. Br J Anaesth 2004; 93: 761-7 2. Van den Berghe G, Wouter P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. New Engl J Med 2001; 345: 1359-67. Conflict of Interest:None declared |
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