Physiological and metabolic response to isolated closed-head injury

Part 1: Basal metabolic state: correlations of metabolic and physiological parameters with fasting and stressed controls

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✓ Studies of the metabolic and physiological response to closed-head injury have intimated the presence of persistent hypermetabolism. To more fully define and evaluate the metabolic response to head trauma, a prospective study was conducted in patients with isolated closed-head injuries. Metabolic and cardiopulmonary data were obtained for a 7-day period. Patients with multiple injuries or infections, or those who received steroids, were excluded. The basic treatment regimen utilized hyperventilation, bed rest with head elevation, intracranial pressure monitoring, mild fluid restriction, and mannitol as needed. No exogenous nutritional support was given. Intrastudy trends and comparsion with data from unstressed fasting patients and stressed patients were noted. Mean Glasgow Coma Scale scores were 4.4 ± 1.5 initially, but rose to a mean of 8.2 ± 3.7 by Day 7. While the responses of cardiac index, CO2 production, lactate/pyruvate ratio, and arteriovenous O2 content difference (AVO2D) were initially elevated, these parameters declined over the course of 7 days. The AVO2D was equivalent to the fasting level by Day 5. Metabolic data, including most amino acid levels in plasma, showed an initial equivalence to stress control levels and a pattern similar to that in non-stressed control subjects by Day 7. Nitrogen and 3-methyl histidine excretion were persistently elevated for the full 7 days. Patients with isolated closed-head injury seemed to be initially hypermetabolic, but this process appeared to resolve by 1 week; the persistent nitrogen excretion may reflect equilibration of muscle mass to the existing level of activity (bed rest). After the first few days, nitrogen excretion may give an erroneous index of the level of metabolic stress and the type or amount of nutritional support needed.

Article Information

Address reprint requests to: Clifford S. Deutschman, M.S., M.D., Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland 21205.

© AANS, except where prohibited by US copyright law.

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Figures

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    Changes in cardiac index (CI, liters/min/sq m) during 7 days post-injury. While values are elevated relative to both stressed and fasting control groups, a clear peak is noted on Day 3 with subsequent decline.

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    Production of CO2 during 7 days post-injury, with control levels as indicated. Production of CO2 in the study patients was equivalent to control levels by Day 3. A similar pattern was observed for the arteriovenous O2 content difference and the lactate/pyruvate ratio.

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    Metabolic data obtained in patients and controls*

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    Glucose and triglyceride levels during 7 days postinjury. Values for glucose were significantly different from stressed control levels by Day 4 and without significant difference from fasting control by Day 6. A clear decline is noted. Triglyceride values rose progressively over time, a finding consistent with progressive starvation.

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    Urinary urea nitrogen (UUN) during 7 days postinjury. While elevated relative to stressed control values throughout the study, a clear peak occurs at Day 3. Levels remain constant from Day 5 onward.

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    Urinary 3-methyl histidine (3-MH) during 7 days post-injury. While elevated relative to stressed control values throughout the study, a clear peak occurs at Day 3. Levels remain constant from Day 5 onward.

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    Circlegram comparing the arteriovenous O2 content difference (AVO2D) and nine amino acids with control values. ABU = α-amino-n-butyric acid. Heavy inner circle represents mean values for individual variables, each of which is noted on a ray. Each broken circle represents two standard deviations from each mean. Left: Comparison of study values with data from the stressed control group. Data from study Day 1 are indicated by the heavy line connecting means for individual variables, and this lies very close to control values. Data from study Day 7 are represented by the heavy broken line and deviate widely from control. Right: Comparison of study values with data from the unstressed fasting control group. Wide deviation is noted on Day 1 (heavy black line), while good correlation is present by Day 7 (heavy broken line).

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