Physiological and metabolic response to isolated closed-head injury

Part 2: Effects of steroids on metabolism. Potentiation of protein wasting and abnormalities of substrate utilization

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  • 1 Department of Surgery, University of Minnesota School of Medicine, Minneapolis, and Department of Dietetics and The Surgical-Metabolic Research Facility, St. Paul-Ramsey Medical Center, St. Paul, Minnesota; and Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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✓ In order to determine the effects of steroid administration on the metabolic response to isolated closed-head injury, a longitudinal study was performed. Metabolic indices were prospectively evaluated for the first 5 days postinjury in six patients who received steroids and 10 patients who did not. Patients were carefully screened to eliminate those with associated injuries as well as those with abnormalities due to sepsis. Other than steroid administration, a uniform treatment regimen was used in both groups. Metabolic indices measured on postinjury Days 1, 3, and 5 were analyzed. In addition, data were compared to results in large data banks obtained both from overnight-fasted patients (fasted controls) and from polytrauma victims (stressed controls). Both treatment groups were comparable with respect to age, mean Glasgow Coma Scale scores on admission and on Day 5, and initial intracranial pressure. Metabolic data indicated significantly higher levels of nitrogen excretion and somatic protein mobilization in steroid-treated patients than in patients not receiving steroids. In both groups, glucose levels, the lactate/pyruvate ratio, and branched-chain amino acid levels (all metabolic indices that correlate well with level of stress) initially corresponded to values for stressed controls. By Day 5, values for these variables were similar to fasted controls for the group not receiving steroids. In patients receiving steroids, however, the data remained similar to those for stressed controls. It is concluded that steroids prolong the metabolic abnormalities associated with the initial phase of head injury. In view of inconclusive data regarding benefit from steroid administration, serious questions must be raised regarding the use of these catabolic agents in this setting.

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Contributor Notes

Address reprint requests to: Clifford S. Deutschman, M.D., Department of Anesthesiology and Critical Care Medicine, Blalock 14, Johns Hopkins Hospital, Baltimore, Maryland 21205.
  • 1.

    Alexander E Jr: Medical management of closed head injuries. Clin Neurosurg 19:240250, 1972 Alexander E Jr: Medical management of closed head injuries. Clin Neurosurg 19:240–250, 1972

    • Search Google Scholar
    • Export Citation
  • 2.

    Askanazi J, , Carpentier YA, & Elwyn DH, et al: Influence of total parenteral nutrition on fuel utilization in injury and sepsis. Ann Surg 191:4046, 1980 Askanazi J, Carpentier YA, Elwyn DH, et al: Influence of total parenteral nutrition on fuel utilization in injury and sepsis. Ann Surg 191:40–46, 1980

    • Search Google Scholar
    • Export Citation
  • 3.

    Birge SJ: The role of glucocorticoids in muscle metabolism. Adv Exp Med Biol 171:5360, 1984 Birge SJ: The role of glucocorticoids in muscle metabolism. Adv Exp Med Biol 171:53–60, 1984

    • Search Google Scholar
    • Export Citation
  • 4.

    Cerra FB: Multiple system organ failure: the sequelae of the systemic inflammatory response. J Clin Nutr (In press, 1987)Cerra FB: Multiple system organ failure: the sequelae of the systemic inflammatory response. J Clin Nutr (In press, 1987)

    • Search Google Scholar
    • Export Citation
  • 5.

    Clifton GL, , Robertson CS, & Grossman RG: Nutritional response to severe head injury. Surg Forum 34:538539, 1983 Clifton GL, Robertson CS, Grossman RG: Nutritional response to severe head injury. Surg Forum 34:538–539, 1983

    • Search Google Scholar
    • Export Citation
  • 6.

    Clifton GL, , Robertson CS, & Grossman RG, et al: The metabolic response to severe head injury. J Neurosurg 60:687696, 1984 Clifton GL, Robertson CS, Grossman RG, et al: The metabolic response to severe head injury. J Neurosurg 60:687–696, 1984

    • Search Google Scholar
    • Export Citation
  • 7.

    Cooper PR, , Moody S, & Clark WK, et al: Dexamethasone and severe head injury. A prospective double-blind study. J Neurosurg 51:307316, 1979 Cooper PR, Moody S, Clark WK, et al: Dexamethasone and severe head injury. A prospective double-blind study. J Neurosurg 51:307–316, 1979

    • Search Google Scholar
    • Export Citation
  • 8.

    Deutschman CS, , Konstantinides FN, & Raup S, et al: 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. J Neurosurg 64:8998, 1986 Deutschman CS, Konstantinides FN, Raup S, et al: 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. J Neurosurg 64:89–98, 1986

    • Search Google Scholar
    • Export Citation
  • 9.

    Faupel G, , Reulen HJ, & Müller D, et al: Double-blind study on the effects of steroids on severe closed head injury, in Pappius HM, & Feindel W (eds): Dynamics of Brain Edema. Berlin: Springer-Verlag, 1976, pp 337343 Faupel G, Reulen HJ, Müller D, et al: Double-blind study on the effects of steroids on severe closed head injury, in Pappius HM, Feindel W (eds): Dynamics of Brain Edema. Berlin: Springer-Verlag, 1976, pp 337–343

    • Search Google Scholar
    • Export Citation
  • 10.

    Felig P, , Owen OE, & Wahren J, et al: Amino acid metabolism during prolonged starvation. J Clin Invest 48:584594, 1969 Felig P, Owen OE, Wahren J, et al: Amino acid metabolism during prolonged starvation. J Clin Invest 48:584–594, 1969

    • Search Google Scholar
    • Export Citation
  • 11.

    Fishman RA: Brain edema. N Engl J Med 293:706711, 1975 Fishman RA: Brain edema. N Engl J Med 293:706–711, 1975

  • 12.

    Galicich JH, & French LA: Use of dexamethasone in the treatment of cerebral edema resulting from brain tumors and brain surgery. Am Pract Dig 12:169174, 1961 Galicich JH, French LA: Use of dexamethasone in the treatment of cerebral edema resulting from brain tumors and brain surgery. Am Pract Dig 12:169–174, 1961

    • Search Google Scholar
    • Export Citation
  • 13.

    Gobiet W: The influence of various doses of dexamethasone on intracranial pressure in patients with severe head injury, in Pappius HM, & Feindel W (eds): Dynamics of Brain Edema. Berlin: Springer-Verlag, 1976, pp 351355 Gobiet W: The influence of various doses of dexamethasone on intracranial pressure in patients with severe head injury, in Pappius HM, Feindel W (eds): Dynamics of Brain Edema. Berlin: Springer-Verlag, 1976, pp 351–355

    • Search Google Scholar
    • Export Citation
  • 14.

    Hooshmand H, , Dove J, & Houff S, et al: Effects of diuretics and steroids on CSF pressure. A comparative study. Arch Neurol 21:499509, 1969 Hooshmand H, Dove J, Houff S, et al: Effects of diuretics and steroids on CSF pressure. A comparative study. Arch Neurol 21:499–509, 1969

    • Search Google Scholar
    • Export Citation
  • 15.

    Hoyt HJ, , Goldstein FP, & Reigel DH, et al: Clinical evaluation of highly water-soluble steroids in the treatment of cerebral edema of traumatic origin (a double-blind study). Clin Pharmacol Ther 13:141, 1972 (Abstract) Hoyt HJ, Goldstein FP, Reigel DH, et al: Clinical evaluation of highly water-soluble steroids in the treatment of cerebral edema of traumatic origin (a double-blind study). Clin Pharmacol Ther 13:141, 1972 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 16.

    Klatzo I: Neuropathological aspects of brain edema. J Neuropathol Exp Neurol 26:114, 1967 Klatzo I: Neuropathological aspects of brain edema. J Neuropathol Exp Neurol 26:1–14, 1967

    • Search Google Scholar
    • Export Citation
  • 17.

    Kobrine AI, & Kempe LG: Studies in head injury — Part II: Effects of dexamethasone on traumatic brain swelling. Surg Neurol 1:3842, 1973 Kobrine AI, Kempe LG: Studies in head injury — Part II: Effects of dexamethasone on traumatic brain swelling. Surg Neurol 1:38–42, 1973

    • Search Google Scholar
    • Export Citation
  • 18.

    Koide T, , Wieloch TW, & Siesjö BK: Chronic dexamethasone pretreatment aggravates ischemic brain damage by inducing hyperglycemia. J Cereb Blood Flow Metab 6:395404, 1986 Koide T, Wieloch TW, Siesjö BK: Chronic dexamethasone pretreatment aggravates ischemic brain damage by inducing hyperglycemia. J Cereb Blood Flow Metab 6:395–404, 1986

    • Search Google Scholar
    • Export Citation
  • 19.

    Molofsky WJ: Steroids and head trauma. Neurosurgery 15:424426, 1984 Molofsky WJ: Steroids and head trauma. Neurosurgery 15:424–426, 1984

    • Search Google Scholar
    • Export Citation
  • 20.

    Owen OE, & Cahill GF Jr: Metabolic effects of exogenous glucocorticoids in fasted man. J Clin Invest 52:25962605, 1973 Owen OE, Cahill GF Jr: Metabolic effects of exogenous glucocorticoids in fasted man. J Clin Invest 52:2596–2605, 1973

    • Search Google Scholar
    • Export Citation
  • 21.

    Pappius HM, & McCann WP: Effects of steroids on cerebral edema in cats. Arch Neurol 20:207216, 1969 Pappius HM, McCann WP: Effects of steroids on cerebral edema in cats. Arch Neurol 20:207–216, 1969

    • Search Google Scholar
    • Export Citation
  • 22.

    Rapp RP, , Young B, & Twyman D, et al: The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg 58:906912, 1983 Rapp RP, Young B, Twyman D, et al: The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg 58:906–912, 1983

    • Search Google Scholar
    • Export Citation
  • 23.

    Robertson CS, , Clifton GL, & Goodman JC: Steroid administration and nitrogen excretion in the head-injured patient. J Neurosurg 63:714718, 1985 Robertson CS, Clifton GL, Goodman JC: Steroid administration and nitrogen excretion in the head-injured patient. J Neurosurg 63:714–718, 1985

    • Search Google Scholar
    • Export Citation
  • 24.

    Sapolsky RM, & Pulsinelli WA: Glucocorticoids potentiate ischemic injury to neurons: therapeutic implications. Science 229:13971400, 1985 Sapolsky RM, Pulsinelli WA: Glucocorticoids potentiate ischemic injury to neurons: therapeutic implications. Science 229:1397–1400, 1985

    • Search Google Scholar
    • Export Citation
  • 25.

    Saul TG, , Ducker TB, & Salcman M, et al: Steroids in severe head injury. A prospective randomized clinical trial. J Neurosurg 54:596600, 1981 Saul TG, Ducker TB, Salcman M, et al: Steroids in severe head injury. A prospective randomized clinical trial. J Neurosurg 54:596–600, 1981

    • Search Google Scholar
    • Export Citation
  • 26.

    Smith OK, & Long CNH: Effect of cortisol on plasma amino nitrogen of eviscerated adrenalectomized-diabetic rats. Endocrinology 80:561566, 1967 Smith OK, Long CNH: Effect of cortisol on plasma amino nitrogen of eviscerated adrenalectomized-diabetic rats. Endocrinology 80:561–566, 1967

    • Search Google Scholar
    • Export Citation
  • 27.

    Tomas FM, , Munro HN, & Young VR: Effect of glucocorticoid administration on the rate of muscle protein breakdown in vivo in rats, as measured by urinary excretion of methylhistidine. Biochem J 178:139146, 1979 Tomas FM, Munro HN, Young VR: Effect of glucocorticoid administration on the rate of muscle protein breakdown in vivo in rats, as measured by urinary excretion of methylhistidine. Biochem J 178:139–146, 1979

    • Search Google Scholar
    • Export Citation
  • 28.

    Wagle SR: Effects of insulin deficiency and cortisol administration on mobilization of protein to gluconeo-genesis. Proc Soc Exp Biol Med 121:12971300, 1966 Wagle SR: Effects of insulin deficiency and cortisol administration on mobilization of protein to gluconeo-genesis. Proc Soc Exp Biol Med 121:1297–1300, 1966

    • Search Google Scholar
    • Export Citation
  • 29.

    Wilmore DW, , Aulick LH, & Becker RA: Hormones and the control of metabolism, in Fischer JE (ed): Surgical Nutrition. Boston: Little, Brown & Co, 1983, pp 6595 Wilmore DW, Aulick LH, Becker RA: Hormones and the control of metabolism, in Fischer JE (ed): Surgical Nutrition. Boston: Little, Brown & Co, 1983, pp 65–95

    • Search Google Scholar
    • Export Citation
  • 30.

    Young B, , Ott L, & Norton J, et al: Metabolic and nutritional sequelae in the non-steroid treated head injury patient. Neurosurgery 17:784791, 1985 Young B, Ott L, Norton J, et al: Metabolic and nutritional sequelae in the non-steroid treated head injury patient. Neurosurgery 17:784–791, 1985

    • Search Google Scholar
    • Export Citation

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