Clinical Neurology and Neurosurgery 116 (2014) 4– 8
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Clinical Neurology and Neurosurgery
journa l h om epa ge : www.elsev ier .com/ locate /c l ineuro
survey of routine treatment of patients with intracranialypertension (ICH) in specialized trauma centers in Sao Paulo, Brazil:
11 million metropole!
arcela B. Alitha, Milena C. Vidottob, José R. Jardimc,∗, Mariana R. Gazzottid
Research fellow of the Neurosurgery Physiotherapy Research Group of the Respiratory Division at Escola Paulista de Medicina at Federal University of Sãoaulo (Unifesp/EPM), Rua dos Ac ores, 310, 1◦ andar, São Paulo 04032-010, BrazilPhysiotherapy Department at Unifesp/EPM, Rua dos Ac ores, 310, 1◦ andar, São Paulo 04032-010, BrazilRespiratory Division at EPM, Director of the Pulmonary Rehabilitation Center at Unifesp/EPM, São Paulo, BrazilCoordinator of the Neurosurgery Physiotherapy Research Group of the Respiratory Division at Unifesp/EPM, Rua dos Ac ores, 310. 1◦ andar, São Paulo4032-010, Brazil
r t i c l e i n f o
rticle history:eceived 18 April 2013eceived in revised form 31 October 2013ccepted 9 November 2013vailable online 16 November 2013
a b s t r a c t
Objective: A survey of intensive care units (ICU) in São Paulo that care for patients with TBI and ICH usingthe hyperventilation technique.Methods: A questionnaire was given to the physiotherapist coordinator at 57 hospitals in São Paulo, where24-h neurosurgery service is provided.Results: Fifty-one (89.5%) hospitals replied. From this total, thirty-four (66.7% perform the hyperventila-
tion technique, 30 (85%) had the objective to reach values below 35 mmHg, four (11%) levels between35 mmHg and 40 mmHg and one (3%) values over 40 mmHg.Conclusions: We concluded that most hospitals in São Paulo perform hyperventilation in patients withsevere brain trauma although there are not any specific Brazilian guidelines on this topic. Widespreadcontroversy on the use of the hyperventilation technique in patients with severe brain trauma highlights
bal p
the need for a specific Glo
. Introduction
Intracranial hypertension (ICH) is the most critical and poten-ially devastating complication and most serious concern inatients with brain injury. Usually ICH is defined as an increase inhe intracranial pressure (ICP) that occurs when there is an increasen any cerebral component volume, which exceeds the capacityf blood flow cerebral autoregulation [1]. The treatment protocolor ICH has two focused objectives: one focuses on the reductionf ICP including therapies such as controlled mechanical ventila-ion, administration of hyperosmotic solutions, and barbiturates;he other is focused on the maintenance of normal cerebral bloodow and cerebral perfusion pressure including the hyperventila-ion technique [2].
Hyperventilation can cause a rapid decline in ICP due to cere-ral vasoconstriction where the vessels are still reacting to changes
n partial carbon dioxide arterial pressure (PaCO2) [3–5]. However,
the vasoconstriction effect on the brain arterioles caused by hyper-ventilation lasts from 11 to 20 h and after this time a reboundvasodilatation effect occurs due to local lactoacidosis and hypoxialeading to an increase in cerebral blood flow and deterioration inICH [6,7].
The third edition of the Guidelines for the Management of SevereTraumatic Brain Injury (TBI) (2007) does not recommend the useof hyperventilation due to insufficient evidence for its use. Accord-ing to these Guidelines, independent of hyperventilation, cerebralblood flow can drop dangerously low in the first hours followingsevere TBI and the introduction of hyperventilation could fur-ther decrease cerebral blood flow, contributing to the likelihoodof ischemia [8].
However this strategy is still used in Europe to treat patientswith severe TBI. A retrospective study conduced in 22 centers inEurope concluded that hyperventilation is used extensively, inten-tionally or otherwise, in the treatment of severe TBI. While theoverall adherence to the third edition of the Guidelines for the Man-agement of Severe TBI seems to be the rule, their recommendations
on early prophylactic hyperventilation (PaCO2 < 35 mmHg) andadditional cerebral oxygenation monitoring during forced hyper-ventilation are not followed in the majority of European TBI centers[9]. According to this study, there is evident controversy on the
atter of hyperventilation between the American Guidelines anduropean countries.
A Brazilian Guidelines on Severe TBI does not exist but there is aecommendation to avoid using hyperventilation in these patients.t is not known how these patients are currently being treated inrazil. São Paulo is a vast metropolis with approximately 11 million
nhabitants, thus a high incidence of trauma and a large number ofpecialized hospitals on TBI. A survey in the local ICU on the usef hyperventilation technique in severe TBI may give us an ideaf these hospitals are following the American or European recom-
endations.Thus, the objective of this study was to survey the intensive care
nits (ICU) in São Paulo that provide care to patients with TBI andCH on the use of the hyperventilation technique.
. Methods
.1. Sample selection
A list of all hospitals in São Paulo with an ICU was obtainedrom the City Health Registry and from the web site of the Nationalegistry of Health Facilities (cnes.datasus.gov.br). Hospitals wereontacted by telephone in order to check if they would meet thenclusion criteria.
.2. Questionnaire
Initially three professionals with expertise in neurologicalntensive care designed a questionnaire on the utilization of hyper-entilation in patients with ICH. The questionnaire was thenvaluated by five physiotherapists working in ICU’s with neurosur-ical services in order to evaluate its understanding and relevance.he physiotherapists’ suggestions helped to establish the final ver-ion of the questionnaire (Fig. 1). The questionnaire was sent to7 hospitals that met the inclusion criteria: ICU in the hospitalith a neurosurgical service, 24 h physiotherapist coverage, with
physiotherapist in charge of the physiotherapist group with ainimum of one year experience in intensive care. A hospital was
xcluded after it failed to answer our queries. The period of dataollection was from January 2010 to July 2010. The questionnaireas answered by the physiotherapist in charge of the ICU.
This study protocol and the consent from were approved bythics Committee of the Federal University of São Paulo.
Numerical variables were expressed as mean ± standard devi-tion for homogeneous data and as median and percentile in thease of heterogeneous data. Categorical variables were describeds frequencies and percentages.
. Results
Among the 186 health institutions listed in January 2010 by theity Health Registry and the website of the National Registry ofealth Facilities (cnes.datasus.gov.br), 154 were hospitals and 57f them met the inclusion criteria. The questionnaire was sent tohese hospitals and 51 (89.5%) answered. (Fig. 2).
Table 1 shows the number of ICU beds and the number ofatients seen with severe ICH per year per hospital.
With regard to the question whether the hyperventilationas performed in patients with ICH, 34 (66.7%) physiotherapists
nswered that this strategy was routinely performed and 17 (33.3%)o not perform it. Regarding the calculation of cerebral extraction
f oxygen (CEO2), 41 (80.4%) of the ICU’s do not perform it.
As regards the minimum allowed PaCO2 value during the hyper-entilation, from the 35 hospitals that performed this method (85%)ad the objective of reaching values below 35 mmHg, four (11%)
ICU, intensive care unit; ICH, intracranial hypertension.a Median (percentile 25–75).
levels between 35 mmHg and 40 mmHg, despite the fact that manypeople do not consider values of 35–40 mmHg as hyperventilation,and one (3%) values above 40 mmHg.
4. Discussion
The present study aimed to evaluate the policy of hospitals inthe city of São Paulo with regard to the use of the hyperventila-tion strategy on patients with ICH and found that this strategy isperformed in 66.7% of the hospitals.
We obtained a higher percentage of returned questionnairesthan that found in the literature for the same type of questionnaire.A questionnaire on treatment practices in patients with TBI in reha-bilitation units in the United Kingdom was returned by only 52%of the physicians [10]. Neurosurgeons from the United States onlyreturned 35% of 2.465 questionnaires regarding the treatment ofpatients with TBI [11]. Similarly, in Brazil, in a survey on the profileof physiotherapists working in ICU [12] only 39% of responses wereobtained. In New Zealand 71% of 52 physiotherapists answered aquestionnaire on the physiotherapy management of patients withtraumatic brain injury in order to develop a Guideline on TBI [13].We therefore consider that the 89.5% response rate gives us enoughfacts to support the results obtained.
In relation to the hyperventilation strategy in patients withICH, 66.7% of the consulted hospitals reported that this maneu-ver is regularly performed in their ICU. Only one hospital adoptshyperventilation reaching PaCO2 as low as 20 mmHg, all others thatperform hyperventilation do not go under 28 mmHg of PaCO2. TheBrain Trauma Foundation Guidelines in the USA (2000) states that aPaCO2 below 25 mmHg should always be avoided (evidence level I)and even moderate hyperventilation (PaCO2 31–35 mmHg) shouldnot be performed in the first 24 h due to reduction in cerebral bloodflow (evidence level II) [5]. Others are still more conservative andrecommend that empirical hyperventilation should be avoided incases of severe TBI not only in the first 24 h after injury but for thefirst 5 days post injury since the cerebral blood flow during thisperiod is reduced and the use of hyperventilation in these casesfurther aggravates ischemic lesions [14].
The most recent Guidelines for the Management of Severe TBIin USA (2007) do not recommend the use of hyperventilation dueto insufficient evidence for its use. In addition, it advises that ifhyperventilation is indicated, PaCO2 should not reach 25 mmHg[8]. Intense hyperventilation (PaCO2 ≤ 25 mmHg) was a techniquewidely used in patients with TBI in the 1980’s in order to acquire arapid reduction in ICH. However, studies conducted at that timerevealed that the cerebral blood flow during the first days fol-lowing brain trauma was decreased and hyperventilation causedintense additional cerebral ischemia. At this time histological evi-dence of cerebral ischemia in TBI patients who progressed to death
was found. [8]. Despite the fact that these Guidelines do not recom-mend the use of hyperventilation, this strategy is still widely used inEurope to treat patients with severe TBI [9]. The same was observedin our study. However, in cases of ICH refractory to conventional
6 M.B. Alith et al. / Clinical Neurology and Neurosurgery 116 (2014) 4– 8
Questionnaire 1. How long have you gra dua ted ?
_______ ___ ____ ____ ___ ___.
2. How long have you bee n working
in ICU ?
_______ ___ ____ ____ ___ ___.
3. How many patients do you see in
a work period?
_______ ___ ____ ____ ___ ___.
4. Is there a physioth erap y serv ice
during 24 hou rs in yo ur hospital ?
( ) Ye s ( ) No
5. Is there a Neuro log ic ICU in the
hospital you work at ?
( ) Ye s ( ) No
6. How many sev ere neuro log ic
patients wit h intracr anial dis eases
do you see per year ?
( ) < 5 pati ents
( ) > 5 – 10 patients
( ) >10 – 20 patients
( ) > 20 patient s
7. In the hospital you work , do you
see patients with intracranial
hypertension?
( ) Ye s ( ) No
8. Is there a Neur osurgery servic e in
your hospita l?
( ) Ye s ( ) No
9. Do you use the hy perventilation
techn ique for patients wit h intracranial
hypertension?
( ) Ye s ( ) No
10. If yes, what is the minimum CO2
value reache d?
____ ___ ______ ____ .
11. If you use the hy perventilatio n
techn ique, does that bring any co ncer n
to you?
( ) Ye s ( ) No
12. If ye s, why?
_______ ___ ____ ____ ___ ____ __.
13. Do you usually eval uate the jugul ar
bulb saturati on?
( ) Ye s ( ) No
14. Do you usually evaluate the
cerebral extr action of oxig en?
( ) Ye s ( ) No
15. Do you perf orm resp irator y
physiotherap y techni ques in patien ts
with intr acra nial hyperte nsion ?
( ) Ye s ( ) No
16. If ye s, in whi ch situation?
_______ ___ ____ ____ ___ ____ __.
17. Which resp irat ory physioth erap y
techniqu es do you use?
_______ ___ ____ ____ ___ ____ __.
18. Do you perform motor
physiotherap y in pa tients with
intracranial hyperte nsion?
( ) Ye s ( ) No
19. If ye s, in whi ch situation?
_______ ___ ____ ____ ___ ____ __.
20. Which motor physiotherap y
techniqu es do you use?
_______ ___ ____ ____ ___ ____ __.
21. Is there any protocol in the hospita l
to treat patients wit h intracrania l
hypertension ? Wh ich ones?
( ) Ye s ( ) No
_______ ___ ____ ____ ___ ____ _____ .
22. In the ICU, do you us e
capno gra phy in pat ients wit h
intracranial hyperte nsion?
( ) Ye s ( ) No
uestio
tsol
ifim
Fig. 1. Q
reatment, which includes the optimization of sedation and analge-ia, neuromuscular blockers, drainage of cerebrospinal fluid, hyper-smolar therapy and in cases of brain herniation and acute neuro-ogical deterioration, hyperventilation may be necessary [15–17].
CEO2 calculation in patients with ICH is not a routine procedure
n the hospitals of São Paulo. However, according to the Guidelinesor the Management of Severe TBI (2007) [8], if hyperventilations required, the measurement of CEO2 is mandatory and should be
aintained between 24% and 42% [18,19].
nnaire.
In cases where endotracheal suctioning is performed on patientswith severe brain trauma presenting ICH 30 mmHg, one should bealert that ICH may increase without increasing mean arterial pres-sure [20]. However, for values of ICP above 30 mmHg there is nostudy that has proven the safety of respiratory techniques. Chest
percussion performed for prevention of pneumonia in patients withICH showed stability of ICP, during and after the procedure [21]. Inthe same way manual vibrocompression did not increase ICH orcerebral perfusion pressure [22].
M.B. Alith et al. / Clinical Neurology and Neurosurgery 116 (2014) 4– 8 7
Hospitals(n = 154)
Hospitals without 24-hour physiotherapy
(n = 59)
Hospitals without
NeurosurgeryService (n = 38)
Eligible hospitals (n = 57)
Hospitals that did not answer the
questionnaire(n = 6 )
Hospitals that answered the questionnaire
(n = 51)
Privatehospitals (n = 44)
Publichospitals (n = 7)
Available Health Institutions(n = 186)
s in Sã
pin
osalhswi
Fig. 2. Flow chart of the selected hospital
If motor physiotherapy techniques as passive mobilization andositioning are used in patients with ICH [23] the recommendation
s that patient should be kept with the head elevated to 30◦ in aeutral position to promote venous brain drainage [7,14,15].
From this study, we concluded that most hospitals in the cityf São Paulo routinely perform hyperventilation in patients withevere brain trauma, although its efficacy has not been establishednd its routine use has not been recommended in the TBI Guide-ines published in 2007. Widespread controversy on the use of the
yperventilation technique in patients with severe brain traumatill exists. It is suggested that more consensus and evidentiaryork needs to be conducted and that this has to reach out to the
nternational community.
o Paulo City, Brazil eligible for the study.
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