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      Mild decrease in heart rate during early phase of targeted temperature management following tachycardia on admission is associated with unfavorable neurological outcomes after severe traumatic brain injury: a post hoc analysis of a multicenter randomized controlled trial

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          Abstract

          Background

          The association between isolated admission heart rate (HR) and prognosis has been discussed, but not that between gross HR change and neurological outcome in patients with severe traumatic brain injury (TBI). In the acute phase of severe TBI, HR is influenced by several factors (e.g., pain, sympathetic activation, hypovolemia, fever, body temperature). Therefore, admission HR and gross HR change should be examined in patients with TBI treated with a well-designed protocol, such as was done in the Brain Hypothermia (B-HYPO) Study.

          Methods

          This was a post hoc analysis of the B-HYPO Study, which was conducted as a prospective, multicenter, randomized controlled trial in patients with severe TBI receiving mild therapeutic hypothermia (MTH; 32.0 °C–34.0 °C) or fever control (35.5 °C–37.0 °C) in Japan. Patients with MTH were examined, and HR change (%HR) in the early MTH phase was calculated as follows: [admission HR – HR at day 1]/admission HR × 100. Patients were divided into six groups, using admission HR (< 80, 80–99, ≤ 100) and median of %HR; i.e., group (Admission HR < 80 and %HR ≥ 18.6); group (Admission HR < 80 and %HR < 18.6); group (Admission HR 80–99 and %HR ≥ 18.6); group (Admission HR 80–99 and %HR < 18.6); group (Admission HR ≥100 and %HR ≥ 18.6); and group (Admission HR ≥100 and %HR < 18.6). The primary outcome was an adjusted predicted probability of unfavorable neurological outcome at 6 months after TBI according to Glasgow Outcome Scale score, which is a measure of functional recovery and defined as severe disability, persistent vegetative state, and death.

          Results

          Overall, 79 patients with MTH (52.7% of the original trial) were examined; among these, unfavorable neurological outcomes were observed in 53.2%. Among all the groups, group (Admission HR ≥100 and %HR < 18.6) exhibited the highest proportion of unfavorable outcomes, and 82.3% of patients had an adjusted predicted probability of unfavorable outcomes, whereas those in group (Admission HR < 80 and %HR ≥ 18.6) developed only 22.8% ( p = 0.04).

          Conclusions

          Mild HR decrease during the early phase of targeted temperature management following tachycardia at admission can be associated with unfavorable neurological outcomes after severe TBI.

          Electronic supplementary material

          The online version of this article (10.1186/s13054-018-2276-6) contains supplementary material, which is available to authorized users.

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          Most cited references 27

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          Lack of effect of induction of hypothermia after acute brain injury.

          Induction of hypothermia in patients with brain injury was shown to improve outcomes in small clinical studies, but the results were not definitive. To study this issue, we conducted a multicenter trial comparing the effects of hypothermia with those of normothermia in patients with acute brain injury. The study subjects were 392 patients 16 to 65 years of age with coma after sustaining closed head injuries who were randomly assigned to be treated with hypothermia (body temperature, 33 degrees C), which was initiated within 6 hours after injury and maintained for 48 hours by means of surface cooling, or normothermia. All patients otherwise received standard treatment. The primary outcome measure was functional status six months after the injury. The mean age of the patients and the type and severity of injury in the two treatment groups were similar. The mean (+/-SD) time from injury to randomization was 4.3+/-1.1 hours in the hypothermia group and 4.1+/-1.2 hours in the normothermia group, and the mean time from injury to the achievement of the target temperature of 33 degrees C in the hypothermia group was 8.4+/-3.0 hours. The outcome was poor (defined as severe disability, a vegetative state, or death) in 57 percent of the patients in both groups. Mortality was 28 percent in the hypothermia group and 27 percent in the normothermia group (P=0.79). The patients in the hypothermia group had more hospital days with complications than the patients in the normothermia group. Fewer patients in the hypothermia group had high intracranial pressure than in the normothermia group. Treatment with hypothermia, with the body temperature reaching 33 degrees C within eight hours after injury, is not effective in improving outcomes in patients with severe brain injury.
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            Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients.

            Increasing age is associated with poorer outcome in patients with closed traumatic brain injury (TBI). It is uncertain whether critical age thresholds exist, however, and the strength of the association has yet to be investigated across large series. The authors studied the shape and strength of the relationship between age and outcome, that is, the 6-month mortality rate and unfavorable outcome based on the Glasgow Outcome Scale. The shape of the association was examined in four prospective series with individual patient data (2664 cases). All patients had a closed TBI and were of adult age (96% < 65 years of age). The strength of the association was investigated in a metaanalysis of the aforementioned individual patient data (2664 cases) and aggregate data (2948 cases) from TBI studies published between 1980 and 2001 (total 5612 cases). Analyses were performed with univariable and multivariable logistic regression. Proportions of mortality and unfavorable outcome increased with age: 21 and 39%, respectively, for patients younger than 35 years and 52 and 74%, respectively, for patients older than 55 years. The association between age and both mortality and unfavorable outcome was continuous and could be adequately described by a linear term and expressed even better statistically by a linear and a quadratic term. The use of age thresholds (best fitting threshold 39 years) in the analysis resulted in a considerable loss of information. The strength of the association, expressed as an odds ratio per 10 years of age, was 1.47 (95% confidence interval [CI] 1.34-1.63) for death and 1.49 (95% CI 1.43-1.56) for unfavorable outcome in univariable analyses, and 1.39 (95% CI 1.3-1.5) and 1.46 (95% CI 1.36-1.56), respectively, in multivariable analyses. Thus, the odds for a poor outcome increased by 40 to 50% per 10 years of age. An older age is continuously associated with a worsening outcome after TBI; hence, it is disadvantageous to define the effect of age on outcome in a discrete manner when we aim to estimate prognosis or adjust for confounding variables.
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              Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial.

              The inconsistent effect of hypothermia treatment on severe brain injury in previous trials might be because hypothermia was induced too late after injury. We aimed to assess whether very early induction of hypothermia improves outcome in patients with severe brain injury. The National Acute Brain Injury Study: Hypothermia II (NABIS: H II) was a randomised, multicentre clinical trial of patients with severe brain injury who were enrolled within 2·5 h of injury at six sites in the USA and Canada. Patients with non-penetrating brain injury who were 16-45 years old and were not responsive to instructions were randomly assigned (1:1) by a random number generator to hypothermia or normothermia. Patients randomly assigned to hypothermia were cooled to 35°C until their trauma assessment was completed. Patients who had none of a second set of exclusion criteria were either cooled to 33°C for 48 h and then gradually rewarmed or treated at normothermia, depending upon their initial treatment assignment. Investigators who assessed the outcome measures were masked to treatment allocation. The primary outcome was the Glasgow outcome scale score at 6 months. Analysis was by modified intention to treat. This trial is registered with ClinicalTrials.gov, NCT00178711. Enrolment occurred from December, 2005, to June, 2009, when the trial was terminated for futility. Follow-up was from June, 2006, to December, 2009. 232 patients were initially randomised a mean of 1·6 h (SD 0·5) after injury: 119 to hypothermia and 113 to normothermia. 97 patients (52 in the hypothermia group and 45 in the normothermia group) did not meet any of the second set of exclusion criteria. The mean time to 35°C for the 52 patients in the hypothermia group was 2·6 h (SD 1·2) and to 33°C was 4·4 h (1·5). Outcome was poor (severe disability, vegetative state, or death) in 31 of 52 patients in the hypothermia group and 25 of 56 in the normothermia group (relative risk [RR] 1·08, 95% CI 0·76-1·53; p=0·67). 12 patients in the hypothermia group died compared with eight in the normothermia group (RR 1·30, 95% CI 0·58-2·52; p=0·52). This trial did not confirm the utility of hypothermia as a primary neuroprotective strategy in patients with severe traumatic brain injury. Copyright © 2011 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                a-inoue@hemc.jp
                hifumitoru@gmail.com
                kuroday@kms.ac.jp
                nnishimoto@huhp.hokudai.ac.jp
                kenfact@kms.ac.jp
                sum-ygc@umin.ac.jp
                yasutaka.ygc@gmail.com
                kdop@med.showa-u.ac.jp
                neu035@osaka-med.ac.jp
                suehiro-nsu@umin.ac.jp
                tmaekawa@yamaguchi-pu.ac.jp
                bhypo_2@umin.ac.jp
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                19 December 2018
                19 December 2018
                2018
                : 22
                Affiliations
                [1 ]GRID grid.471800.a, Department of Emergency, Disaster and Critical Care Medicine, , Kagawa University Hospital, ; 1750-1 Ikenobe, Miki, Kita, Kagawa 761-0793 Japan
                [2 ]Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, 1-3-1 Wakinohamakaigandori, Chuo-ku, Kobe, Hyogo 651-0073 Japan
                [3 ]GRID grid.430395.8, Emergency and Critical Care Medicine, , St. Luke’s International Hospital, ; 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 Japan
                [4 ]ISNI 0000 0004 0378 6088, GRID grid.412167.7, Clinical Research and Medical Innovation Center, , Hokkaido University Hospital, ; Kita 14, Nishi 5, Kita-ku, Sapporo, Hokkaido 060-8648 Japan
                [5 ]Department of Emergency Medicine, Tokuyama Central Hospital, 1-1 Kouda, Shunan, Yamaguchi, 745-8522 Japan
                [6 ]ISNI 0000 0001 0660 7960, GRID grid.268397.1, Advanced Medical Emergency and Critical Care Center, , Yamaguchi University School of Medicine, ; 1-1-1 Minami Kogushi, Ube, Yamaguchi, 755-8505 Japan
                [7 ]ISNI 0000 0000 8864 3422, GRID grid.410714.7, Department of Emergency, Disaster and Critical Care Medicine, , Showa University, ; 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8555 Japan
                [8 ]ISNI 0000 0004 0623 203X, GRID grid.452656.6, Osaka Mishima Emergency Critical Care Center, ; 11-1 Minamiakutagawacho, Takatsuki, Osaka, 569-1124 Japan
                [9 ]ISNI 0000 0004 0617 5055, GRID grid.413007.1, Yamaguchi Prefectural University, ; 3-2-1 Sakurabatake, Yamaguchi City, Yamaguchi 753-8502 Japan
                Article
                2276
                10.1186/s13054-018-2276-6
                6300018
                30567590
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: Japanese Ministry of Health, Labor and Welfare
                Categories
                Research
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                © The Author(s) 2018

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