Medical management of the brain-injured patient

Introduction
Many trials in critical care tend to lump brain injured patients together, which makes it difficult to apply critical care trials to individual patients with particular disorders. Nevertheless it is the best data we have, and this page is an attempt to summarize data that is not easily applicable to any particular disorder.

Oxygenation
==== Intensive Care Unit Randomized Trial Comparing Two Approaches to Oxygen Therapy (ICU-ROX) (2020) ==== This trial randomized 1000 patients to either conservative (FiO2 down to 21% if needed, goal to maintain O2sat within 91-97%) or usual oxygen therapy and showed no difference in number of ventilator free days and no difference in mortality.

The trial included 383 patients with acute brain injury. 18% of patients in the trial had suspected hypoxic-ischemic encephalopathy, 9.3% had TBI, 3.5% had SAH, 2.9% had IPH, 2.7% had CNS infection, 1.7% had ischemic stroke, and 3.1% had other acute brain pathologies. Important subgroups:
 * Acute brain pathology subgroup (n=383)
 * Ventilator free days: no difference
 * GOS-E: no difference, bad outcome in 60.8% conservative group and 63.7% usual group, aOR 0.89 (95% CI 0.56-1.42). Excluding hypoxic-ischemic encephalopathy (n=173), bad outcome was seen in 65.9% of the conservative group and 60.0% of the usual group (aOR 1.32, 95% CI 0.66-2.62).
 * Mortality: no difference
 * Suspected hypoxic-ischemic encephalopathy subgroup (n=164)
 * Ventilator free days: more ventilator free days in the conservative oxygen therapy group (21.1 vs 0, p=0.007).
 * GOS-E: bad outcome in 55% of conservative group and 68% of usual care group, not significant
 * 6 month mortality: 43% conservative group and 59% usual oxygen. This was significant in some statistical analyses and not significant in others.

Vitamin D
==== Vitamin D to Improve Outcomes by Leveraging Early Treatment (VIOLET, 2019) ==== In a non-neurological population. a large enteral dose of Vitamin D3 administered early in critical illness corrected vitamin D levels but had no impact on mortality, or other clinical outcomes.

Venous thromboembolism
Neurocritical care patients should generally receive appropriate VTE prophylaxis unless there is a clear reason not to (e.g. very soon after hemorrhage). This is a Neurocritical Care Society Clinical Performance Measure.

PICC-line associated
In a small randomized trial (n=77), placement of intermittent pneumatic compression devices on the arm with the PICC actually was associated with more DVTs (42% in SCD group vs 16% in control group, p=0.049). Therefore it should not be used.

Central venous access
In a small randomized trial of 152 patients in a neurocritical care unit, patients were randomized to PICC line or central venous catheter (CVC) placement. There were no central-line associated bloodstream infections (CLABSI) in either group. There were more DVTs (4 vs. 0) in the PICC line group and 1 case of insertional trauma in the CVC group. There was no significant difference in overall number of complications.