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Critical evaluation of the Lund concept for treatment of severe traumatic head injury, 25 years after its introduction

Grande, Per Olof LU (2017) In Frontiers in Neurology 8.
Abstract

When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain... (More)

When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.

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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Brain injury, Brain perfusion, Intracranial monitoring, Neuro-intensive care, Neuroinflammation, Neuroradiology, The Lund concept, The penumbra zone
in
Frontiers in Neurology
volume
8
publisher
Frontiers
external identifiers
  • scopus:85022219950
  • wos:000404835700001
ISSN
1664-2295
DOI
10.3389/fneur.2017.00315
language
English
LU publication?
yes
id
cfca7ae9-7fae-41df-8bda-5fd14b8d9255
alternative location
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5495987/
date added to LUP
2017-07-26 08:11:28
date last changed
2017-09-18 11:39:30
@article{cfca7ae9-7fae-41df-8bda-5fd14b8d9255,
  abstract     = {<p>When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.</p>},
  articleno    = {315},
  author       = {Grande, Per Olof},
  issn         = {1664-2295},
  keyword      = {Brain injury,Brain perfusion,Intracranial monitoring,Neuro-intensive care,Neuroinflammation,Neuroradiology,The Lund concept,The penumbra zone},
  language     = {eng},
  month        = {07},
  publisher    = {Frontiers},
  series       = {Frontiers in Neurology},
  title        = {Critical evaluation of the Lund concept for treatment of severe traumatic head injury, 25 years after its introduction},
  url          = {http://dx.doi.org/10.3389/fneur.2017.00315},
  volume       = {8},
  year         = {2017},
}