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Biomedical subjects

Julio Cruz

Publications and source records attributed to Julio Cruz.

6 recordsLinked to original sources
PubMed2003

Expensive cerebral blood flow measurements alone are useless and misinformative in comatose patients: a comprehensive alternative.

Since the first report addressing quantification of cerebral blood flow (CBF), concomitant assessment of cerebral oxygen consumption was also carried out. Over the years, however, some investigators have emphatically and mistakenly addressed cerebral ischemia in comatose patients, on the basis of CBF measurements alone. In contrast, we have repeatedly reported that ischemia in these patients must be precisely evaluated based on CBF-metabolism coupling or uncoupling, rather than CBF alone. Based on these previous findings, we therefore propose a comprehensive alternative approach, namely the evaluation of brain ischemia in comatose patients based on cerebral metabolic parameters, such as cerebral extraction of oxygen or cerebral lactate release, without expensive CBF measurements.

Brain Ischemia↗
PubMed2002

Cerebral extraction of oxygen and intracranial hypertension in severe, acute, pediatric brain trauma: preliminary novel management strategies.

OBJECTIVE: To evaluate long-term clinical outcomes after severe, acute, pediatric brain trauma, in relation to cerebral extraction of oxygen (CEO(2)) and intracranial pressure abnormalities treated with a protocol to simultaneously normalize both parameters. METHODS: Forty-five acutely comatose children who had sustained severe, non-missile brain trauma were prospectively evaluated and treated according to a protocol to maintain normalized values not only for intracranial pressure and perfusion pressure but also for CEO(2) (the arteriojugular oxyhemoglobin saturation difference). Six-month clinical outcomes were assessed in relation to physiological abnormalities observed during the acute phase of injury. RESULTS: At 6 months after injury, 37 children (82.2%) had achieved favorable clinical outcomes, whereas eight children (17.8%) had not. The mortality rate was 4.4% (two children only). For the overall series, intracranial hypertension was closely associated with the development of relative cerebral hyperperfusion (decreased CEO(2)), especially after postinjury Day 1. A comparison of data for children with favorable versus unfavorable clinical outcomes revealed statistically significant between-group differences for high intracranial pressure and low CEO(2) values, both of which were more prominent in the unfavorable outcome group. No significant within- or between-group differences with respect to blood pressure were observed. CONCLUSION: In severe, acute, non-missile pediatric brain trauma, phasic physiological patterns demonstrated an association between the development of intracranial hypertension and relative cerebral hyperperfusion (decreased global CEO(2)), especially after postinjury Day 1. Unfavorable clinical outcomes were significantly related to more pronounced intracranial hypertension and more profound concomitant decreases in CEO(2), indicating hyperoxic uncoupling between global cerebral consumption of oxygen and cerebral blood flow.

Acute Disease↗
PubMed2002

Practical and comprehensive guidelines for bedside cerebral hemometabolic multitherapeutic optimization.

In recent years, noncomprehensive "guidelines" were proposed for the management of severe acute brain injuries, focusing strictly on two approaches: 1) to maintain cerebral perfusion pressure anywhere above 70 mm Hg; and 2) to maintain arterial carbon dioxide tension levels above 30 torr. Strictly following these propositions, a recently reported prospective controlled study addressed mortality rates of no less than 75-76%, far worse than mortality rates reported before those "guidelines" were published. As a humanitarian alternative, the present comprehensive guidelines are aimed at addressing practical bedside strategies to manage no only intracranial pressure and cerebral perfusion pressure but also cerebral extraction of oxygen, based on solid previously reported papers which revealed the lowest mortality rates (below 15%) in the pertinent literature, in recent years.

Acute Disease↗
PubMed2002

Major clinical and physiological benefits of early high doses of mannitol for intraparenchymal temporal lobe hemorrhages with abnormal pupillary widening: a randomized trial.

OBJECTIVE: We evaluated long-term clinical outcomes and postoperative physiological findings in acutely comatose patients with nonmissile surgical intraparenchymal temporal lobe hemorrhages and abnormal pupillary widening who received early preoperative high-dose mannitol (HDM) versus conventional dose mannitol treatment in the emergency room. METHODS: One hundred forty-one adult patients with traumatic, nonmissile, acute, intraparenchymal temporal lobe hemorrhages associated with early abnormal pupillary widening were prospectively and randomly assigned to receive emergency preoperative intravenous HDM treatment (approximately 1.4 g/kg; 72 patients) and were compared with a control group that was treated with a lower preoperative mannitol dose (approximately 0.7 g/kg; 69 patients). RESULTS: Early preoperative improvement of abnormal bilateral pupillary widening was significantly more frequent in the study group than in the control group (P < 0.03). The same was true for abnormal unilateral pupillary widening (P < 0.01). Early HDM treatment in the emergency room was also associated with significantly better 6-month clinical outcomes (P < 0.005). The two groups of patients were well matched with respect to diameter of the temporal lobe hemorrhages (approximately 4 cm) as well as timing of clot removal (approximately 2.5 hours after injury). Postoperative physiological findings revealed statistically significant between-group differences, with higher intracranial pressure and lower cerebral extraction of oxygen (global relative cerebral hyperperfusion) in the control group than in the HDM group. Postoperative global brain ischemia (abnormally low arteriojugular lactate difference values) was rare and was found for less than 3% of the patients in both groups. CONCLUSION: Early preoperative HDM administration in the emergency room was associated with improved clinical outcomes for adult comatose patients with acute, nonmissile, intraparenchymal temporal lobe hemorrhages and associated abnormal pupillary widening. Early improvement of bilateral or unilateral pupillary abnormalities and better postoperative control of intracranial hypertension and associated global relative cerebral hyperperfusion seemed to be relevant factors that were related to improved outcomes.

Adult↗