By Anthony FigajiFirst Online:
30 April 2021
Do complex systems improve our care of patients with brain injury? It is easy to argue that they do, at least in concept. The brain is the most complex organ of the human body and even more so when injured. A multitude of pathophysiological changes evolve from primary traumatic brain injury (TBI) and many more from secondary insults, developing a vicious cycle of injury that begets more injury. Moreover, all of our well-meaning attempts to avoid or treat secondary injury can create more trouble, sometimes inadvertently causing further injury. For example, raising blood pressure may reduce the risk of ischemia, but it may cause systemic adverse effects and increase intracranial pressure (ICP) if autoregulation is impaired. How does one treat increased ICP when both its causes and the consequences can vary between patients, and even in one patient over time? Perhaps this is why clinical trials in TBI fail—standard interventions applied homogeneously to large groups of patients produce averaged results that do not tell you if an individual patient would benefit because the injury is too complex and heterogenous.
All of this is more challenging in children, an ever-changing population for whom we have less data. Although in adults, anatomy and physiology are largely static, they vary enormously from birth to age 13 . If we cannot agree on what is a sensible cerebral perfusion pressure (CPP) treatment target in adult TBI, how are we possibly going to do this in a 3- or 9-year-old child?
It is tempting to believe that we can match this complexity with some complexity of our own. Maybe we can make more informed and individualized decisions based on a patient’s unique set of circumstances using advanced monitoring . To do so we would need more information from a patient and better systems to accommodate and process that information. Maybe then we can select therapies for specific patients and titrate that therapy to find the sweet spot where the intervention is maximally effective and minimally harmful.
Many people are trying to do just that. But does it make a difference? How do we show that it benefits patients?Read the full article here.#InvitedEditorialCommentary