Stein NR et al. – Metabolic crisis occurs frequently after traumatic brain injury (TBI) despite adequate resuscitation and controlled intracranial pressure (ICP), and is a strong independent predictor of poor outcome at 6months.

• The authors assessed the effectiveness of a standardized trauma resuscitation protocol in 89 patients with moderate to severe TBI, and determined the frequency of adequate resuscitation.
• Prospective hourly values of heart rate, blood pressure, pulse oximetry, intracranial pressure (ICP), respiratory rate, jugular venous oximetry, and brain extracellular values of glucose, lactate, pyruvate, glycerol, and glutamate were obtained.
• The incidence during the initial 72h after injury of low brain glucose <0.8mmol/L, elevated lactate/pyruvate ratio (LPR) >25, and metabolic crisis, defined as the simultaneous occurrence of both low glucose and high LPR, were determined for the group.

• 5 patients were inadequately resuscitated and eight patients had intractable ICP.
• In patients with successful resuscitation and controlled ICP (n=76), within 72h of trauma, 76 % had low glucose, 93 % had elevated LPR, and 74 % were in metabolic crisis.
• The duration of metabolic crisis was longer in those patients with unfavorable (GOSe≤6) versus favorable (GOSe≥7) outcome at 6months (P=0.011).
• In four multivariate models the burden of metabolic crisis was a powerful independent predictor of poor outcome.