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NATIONAL BOARD OF EXAMINATIONS NEW DELHI

THESIS PROTOCOL

Name of the candidate: Dr. Kishor Kumar

Subject: Neurosurgery

Date of joining :8thFeb 2010

Hospital/Institute : Apollo hospital, Jubilee hills,Hyderabad

Guide :Dr.Rahul Lath Mch. DNB(Neurosurgery), Apollo Hospital

Title of the thesis :Predictors of sepsis in severe head injury A prospective study

9.they found that there are increased levels of pre inflammatory substances in blood with in the first 48 hours following trauma.mainly as a result of sepsis. .Development of multi organ dysfunction was found in the absence of usual etiologic agent like infection or systemic injury in the setting of traumatic brain injury as reported by David Zygun5.1.Significantly modifiable factors that were studied are hypoxia.In astudy by E G Mckeating et al 6 . sepsis perse has not been studied in patient with severe head injury.hypotension and hypovolaemia can all be caused by sepsis.10.Of the patients who succumb.30% with in the first few days2 and 20% much later. 1. Apart from this various other factors also contribute to development of sepsis multi organ dysfunction following traumatic brain injury.1 INTRODUCTION Head injuries are leading cause of death in young .They also found that prolonged elevation of these pro inflammatory agents (especially IL-6) increased the risk of systemic inflammatory response syndrome(SIRS) and adult respiratory distress syndrome(ARDS).hypercapnia.While prognostication of acute severe head injury can be done using the Glasgow coma score3.3 AIMS AND OBJECTIVES OF STUDY y Predicts factors that lead to sepsis in severe head injury. 50% of patient with severe head injury die immediately 1.2 REVIEW OF LITERATURE Sepsis leading to multi organ dysfunction is the major cause of death in survivors following severe traumatic brain injury 4. Non neurological organ dysfuction independent of severity of neurological injury was reported by Zygun et al and he concluded that these are are independently assiociated with poor outcome5.hypotension hypovolumia and coagulopathy 7. there are hardly any studies that predict the development of sepsis in head injury.Though hypoxia.8. .hyprcapnia. 1.This pilot aims to identi fy factors that cause sepsis in a head injured patient.

y Sepsis is a systemic inflammatory response to a bacterial infection and is common complication during the course of treatment of patients with multiple trauma and major surgery. It is important to keep m mind that some of the more occult sources for bacteremia. such as sinusitis. 1.4 Materials and Methods Source of data y Hospital admitted patients above 18 yrs diagnosed with severe head injury on the basis of GCS(<8) 3. the inflammatory response leads to multiple organ failure that can result in death. management of sepsis requires rapid diagnosis and treatment. In fact. and possibly. systemic nutritional support in order to increase the patient's immunological competency. Early diagnosis may be particularly difficult in the patient treated with high-dose barbiturates . y Fundamental techniques for prevention include screening studies such as surveillance pulmonary' cultures. sepsis is one of the top 10 or 12 causes of death in the general population 4 y Sepsis is a significant complication in any patient and is a particular problem in the ICU due to the illness of the patient population and the invasive nature of many treatments and monitoring devices.elimination of sepsis would shift an estimated 1.y To study the out come of patients severe head injury with sepsis.in severe sepsis. In a study by j piek et al11. Multiple organ dysfunction in sepsis is now considered the most common cause of death in non-coronary critical care units. y When prevention is unsuccessful. sepsis is particularly difficult to prevent 12. Due to its multifactorial nature and many venues of origin. can easily be overlooked in the head-injured patient13.5% of all patients from an unfavorable to a favorable outcome category. careful attention to invasive monitors and vascular access lines for early evidence of local infection.

2016 were included. This area of study represents fertile ground for innovative strategies to improve the overalloutcome of severe head injury. 2009 and April 31.The mild hypothermia and systemic anergy often seen in these patients makes it more critical to recognize the secondary indicators of sepsis. Non-neurologic organ dysfunction was measured by the SOFA and APACHEII scoring systems. SAMPLE SIZE : . METHODS: We performed a prospective cohort study at Apollo healthy city centre. the first recognized sign of sepsis in such patients is often septic shock.All patients above 18 years of age with severe head injury are included in the study .for intracranial hypertension. and unexplained cardiovascular hyperdynamism with low sequential vascular response and a falling arteriovenous oxygen content difference14. INCLUSION CRITERIA 1. All patients above 18 years of age and older with severe traumatic brain injury (sTBI) and intensive care unit length of stay > 48 hours between Feb 1. This study demonstrates that the prevention or effective early treatment of sepsis would have a salutary role in improving the outco me from head injury. further increasing the detrimental effects of sepsis. hyperglycemia. This adds the morbidity of hypotension to the patient's complication profile. such as progressive thrombocytopenia. Unfortunately. the tertiary care trauma center servicing south India. 400 Patients of severe head injury .

Consultant Surgeon. 2.EXCLUSION CRITERA 1.V K Bhargava. Chairman of Ethics committee Sr. MD Sr. 3)Dr. DM Sr. MD.patients with quadriplegia due to spinal cord injury after trauma. Sr. MS Paed. MeenaTrehan. MD. DM 2)Dr. COMPOSITION OF CLINICAL ETHICS COMMITTEE : 1) Dr. APPROVAL OF CHAIRMAN OF CLINICAL ETHICS COMMITTEE . Dr. SudhirNaik. MD 4)Dr. Consultant Cardiologist.Consultant Physician. SudhirNaik. Consultant cardiologist Chairman of Ethics Committee .Patients below 18 years of age and above 80 years of age.CardiacAnesthetist. N RaghupathiRao.

Kevin laupland John Kotbeek and Christopha Doig SOFA is superior score forthe determination of non neurologicalorgandysfunction in patient of severe traumatic brain injury. "Traumatic brain injury: Can the consequences be stopped?".Pelletet SJ et al:Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patient.D.trauma 2000:48:8 -14. Randai. Bell JD. Jane.J. Brain injury: epidemiology and pathophysiology".... 8. M.CrebtreeTD.Anthony Marmarou. PMC 2292762.080282.D. LIST OF REFERENCES 1. Baker AJ (April 2008). 9. PMID 12708551.Trauma 2003:54 312 -319. Eisenberg.. J Neurosurg 77:901-907. Marshall. Howard M. Blunt'.DiephuisJC. 1992 Extracranial complications of severe head injury Jurgen Piek.SegerMJ. doi:10. 3. TeasdaleG.D .AACNClin issues 1999:10:85-94..DunhamM. Canadian Medical Association Journal 178 (9): 1163 70. M. 11. Chesnut. Greenwald BD.D. R.Herbingeres of poor oucome the day after severe brain injury:Hypothermia.. M. 6. Lawrence F. and Mary a. PMID 18427091.acidosis and coagulopathy. Mar jan Van Berkum-Clark. Klauber.D.D. PH.N.H.E G Mckeating and PJD Andrews cytokinens and adhesion molecule in acute brain injury . Barbara A. PH. "Congenital and acquired brain injury.1053/apmr. 10.1503/cmaj. Miller MA (March 2003). Melville R. John A.hypoperffusion.Park E.P. 4.50052 . PH. Jennett B: Assessment of coma and impaired consciousness.Mikhail J:The trauma traid of death:Hypothermia..etal :Hypothermia in trauma patient. Lancet 2:81-84.OmertL. doi:10. Archives of Physical Medicine and Rehabilitation 84 (3 Suppl 1): S3 7. M.5.2003.. The Effect of Recombinant Human Erythropoietin (rHuEPO) on Microcircualtory Alteration in Intensive Care Unit Patients With Severe Sepsis and Septic Shock 5.ClaridgeJA.JeremitskyE. 1974. 7.D.hypoxia. 1.British Journal of anaesthesia 1998:80 77 -84.VanKesternRG.LV Cberthiaume.Critical care 2006 10:r115doi:1186/cc5007. 2. A practical scale.L M.D. Burnett DM.. M.etal.David Zygun.infallchirurg 1998:101:742 -749. Foulkes.J. M.

25. Apollo Institute of Hospital Administration. Lemeshow S: Applied Logistic Regression.12. 1992. Consultant. Marshall LF. Suhasini. Apollo Hospitals. 1989 13. pp 225-246 14. Lancet 1:480-484. Jennett B. 4) Dr.Srinivas Reddy Group Director of Medical Education. Chesnut RM. Baltimore: Williams & Wilkins. MD Sr.DM Chairman of Thesis Committee. Consultant Endocrinologist. Infectious Diseases. 1975 COMPOSITION OF SCIENTIFIC (THESIS) COMMITTEE : 1) Dr. SantoshRamakrishnan. Suneetha Reddy. MD HOD of Biochemistry. in Cooper PR (ed): Head Injury. MD. 2) Dr. . Swarnalatha. MD HOD of Histopathology. Hosmer DW. A practical scale. 6) Dr. T. 5) Dr. 3) Dr.New York: John Wiley & Sons. ed 3. Bond M: Assessment of outcome after severe brain damage.Obul Reddy Principal. Bowers -Marshall S: Medical management of elevated intracranial pressure.

Consultant Endocrinologist. NAME OF THE CANDIDATE : Dr Kishorkumar SIGNATURE OF THE CANDIDATE : NAME OF THE GUIDE : Dr. Dr. Apollo Health City.Consultant and HOD Department of Neurosurgery. DM. Rahul Lath Consultant Neurosurgeon. Hyderabad. Hyderabad. SIGNATURE: . AlokRanjan Sr. MD. Apollo Health City.APPROVAL OF CHAIRMAN OF THESIS COMMITTEE. SIGNATURE: HEAD OF THE DEPARTMENT : Dr. Santosh Ramakrishnan. Chairman of Thesis Committee.

Hyderabad. Srinivas Reddy.8 APPROVAL OF SCIENTIFIC COMMITTEE AND ITS COMPOSITION (SIGNATURE OF CANDIDATE) (SIGNATURE OF GUIDE) (HEAD OF DEPARTMENT) .HEAD OF THE INSTITUTION : Dr. Director of Medical Education. SIGNATURE: 1. T. Apollo Health City.

Patient outcome will be determined by the last recorded Glasgow Outcome Scale (GOS) Score14.Yes/No. APACHEII at 24 hrs Maximum: SOFA Score: OTHER INJURIES: Procalcitonin Maximum: Sepsis/Septis shock/Sepsis with MODS. .STUDY PROFORMA A PROSPECTIVE COHORT STUDY OF THE PREDICTORS OF SEPSIS IN SEVERE HEAD INJURY. Which organs are effected: Vasopressors: Dialysis: Max creatinine: INTENSIVE CARE UNIT DETAILS ICU Admission: ICU Discharge: Ventilator duration: Tracheostomy Yes/No: Hospital acquired infection: Ventilator associated pneumonia: Catheter related blood stream infection: Catheter associated urinary tract infections: CULTURES OUT COME AT 3 MONTH. PATIENT DETAILS: Name: Tel: Age: Sex: Address: Occuption: HOSPITAL DETAILS: Date of addmission: Ip no. Date of dicharge: PRESENTATION FEATURES: GCS at presentation: MAP at presentation : Spo2 at presentation : CT SCAN FINDINGS: HTN/DM/CAD/Immunisuppresent: SURGERY.