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Plenary sessions, new research are highlights at 37th Critical Care Congress

By Lisa Kirkland, FACP

From the May ACP Hospitalist, copyright © 2008 by the American College of Physicians

Studies on outcomes of severe traumatic brain injury (TBI) and drug costs in the intensive care unit (ICU) were among the new research presented in Honolulu this February at the Society for Critical Care Medicine’s 37th Critical Care Congress. Following are some highlights of the conference.

Traumatic brain injury. Jamie Cooper, MD, deputy director of the ICU at Alfred Hospital in Melbourne, Australia, discussed outcomes of severe TBI. In the U.S., severe TBI affects 2 million people per year, causes 56,000 deaths, leaves 18,000 survivors with disability and costs $56 billion, Dr. Cooper said. Only 50% of surviving patients with severe TBI go on to have long-term independent neurological function. Trials testing new and novel therapies have, to date, been uniformly unsuccessful. Recent advances have come instead from large, randomized trials of currently controversial therapies: corticosteroid therapy and fluid resuscitation. The SAFE-TBI Study found improved survival and good neurological outcomes when saline was used instead of albumin for resuscitation in TBI patients. Also, the CRASH Trial found increased survival in TBI patients who did not receive early steroids. Current trials of early decompressive craniectomy also hold considerable promise. Dr. Cooper assessed these studies and offered further insight into the treatment of TBI; for example, even the use of low-dose steroids in TBI may negatively affect outcomes, he said.

Attendees listen to a session on shock at the 37th Critical Care Congress.

An award-winning abstract found that genetic variation in an enzyme is a potent risk factor for death from TBI. Carbamyl-phosphate synthetase I is crucial in the urea cycle and in nitric oxide metabolism. The AA genotype carried a 10-fold increase in risk of early death in patients with moderate, but not severe, TBI. Potential explanations may include increases in nitric oxide production, cerebral vasodilatation and intracranial pressure. The authors suggested that future therapies for TBI may include understanding genetically mediated physiologic responses.

Listening to the injured brain. Thomas P. Bleck, FACP, professor of neurology at Evanston Northwestern Healthcare in Evanston, Ill., gave a talk on listening to the injured brain, discussing the use of state-of-the-art neurologic monitors in brain-injured patients. New ways of looking at electroencephalographic data, such as compressed spectral edge monitoring, help improve detection of arrhythmic run or asymmetry of electrical activity. Electrodes implanted under the dura at surgery may detect pathologic vasoconstriction resulting from sustained depolarization; this may have important clinical applications in treating vasospasm. Cerebral microdialysis and intraparenchymal oxygenation monitoring give more information about brain perfusion and metabolism.

Glucose control after brain injury. Another award-winning abstract reported increased brain energy crisis, detected using cerebral microdialysis, when patients received tight glucose control after acute brain injury such as subarachnoid or intracranial hemorrhage, trauma or ischemic stroke. Tight glucose control was associated with low brain glucose. Blood glucose, insulin dosage and cerebral perfusion pressure independently predicted the risk of brain energy crisis, which was an independent predictor of survival. The authors also found that survivors had higher levels of brain glucose than nonsurvivors. They suggested that cerebral microdialysis be used as an adjunctive tool in studies of tight glucose control after acute brain injury.

Drug costs in the ICU. Joseph F. Dasta, professor of pharmacy practice at Ohio State University in Columbus, discussed ICU drug costs and addressed the vital role of the pharmacist on the ICU team. Physicians should look beyond the acquisition costs of a drug, he stressed, and learn appropriate ways to reduce costs without compromising care. Adverse events, drug preparation and administration, and suboptimal dosing cause higher hospital costs and prolonged lengths of stay. By prolonging a patient’s ICU stay, for example, an inexpensive drug can cost the institution an average of $3,500 per day. Multidisciplinary ICU rounds with a clinical pharmacist present can help optimize pharmacotherapy and reduce costs in many cases, Mr. Dasta said.

Dr. Kirkland is a hospitalist at the Mayo Clinic in Rochester, Minn., and a critical care specialist at Abbott Northwestern Hospital in Minneapolis. She is a member of ACP Hospitalist’s editorial advisory board.