• Skip to content
  • Skip to primary sidebar
  • Collections
  • ECG Library
  • Top 100
  • PART ONE
  • CASES
  • CCC
  • Tox Library

Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

Critical Care Compendium | The Lund Concept for Traumatic Brain injury

The Lund Concept for Traumatic Brain injury

by Chris Nickson, Last updated August 18, 2013

OVERVIEW

  • A ‘volume-targeted’ approach to the management of TBI developed by a Swedish group (not ABBA)
  • based on physiological volume regulation of the intracranial compartments
  • The Lund concept contradicts the prevailing strategem of titrating CPP to match ICP in TBI

THEORY

Normal healthy brain

  • The balance between effective transcapillary hydrostatic and osmotic pressures constitutes the driving force for transcapillary fluid exchange
  • The low permeability for sodium and chloride combined with the high crystalloid osmotic pressure (approximately 5700 mmHg) on both sides of the blood-brain barrier (BBB) counteracts fluid exchange across the intact BBB
  • variations in systemic BP  generally are not transmitted to these capillaries because cerebral intracapillary hydrostatic pressure (and blood flow) is tightly autoregulated

In TBI

  •  the BBB may be partially disrupted
  • transcapillary water exchange is determined by the differences in hydrostatic and colloid osmotic pressure between the intra- and extracapillary compartments
  • pressure autoregulation of cerebral blood flow is likely to be impaired in these conditions
  • a high cerebral perfusion pressure increases intracapillary hydrostatic pressure and leads to increased intracerebral water content and an increase in ICP

MANAGEMNT ACCORDING TO THE LUND CONCEPT

Principles

  • The prevention of brain oedema formation to reduce fluid shift from capillaries into brain parenchyma, by preserving capillary colloid osmotic pressure and reducing capillary hydrostatic pressure
  • The improvement of the cerebral microcirculation by the avoidance of arterial vasoconstrictors

Preserve osmotic pressure

  • albumin (considered a contra-indication by some based on SAFE trial subgroup analysis)
  • blood products
  • diuretics

Reduce hydrostatic pressure

  • metoprolol
  • clonidine
  • thiopentone
  • dihydroergotamine (precapillary vasoconstriction)

CPP target

  • if ICP normal aim for 60-70mmHg
  • however, if ICP elevated a CPP of 50mmHg is accepted

Vasoactive use

  • avoid dobutamine (cerebral vasodilatation)
  • avoid noradrenaline (cerebral vasoconstriction)

EVIDENCE

  • improved outcomes compared with historical controls and other institutions have been reported in a few nonrandomized studies
  • until recently had never been subjected to a randomized trial and had never been evaluated outside Sweden
  • one small Bosnian RCT found a mortality benefit for a ‘modified Lund protocol’ in TBI, compared to a CPP targetted approach
  • good evidence against some components of the Lund concept protocol

References and Links

  • Dizdarevic K, Hamdan A, Omerhodzic I, Kominlija-Smajic E. Modified Lund concept versus cerebral perfusion pressure-targeted therapy: a randomised controlled study in patients with secondary brain ischaemia. Clin Neurol Neurosurg. 2012 Feb;114(2):142-8. doi: 10.1016/j.clineuro.2011.10.005. Epub 2011 Oct 28. PubMed PMID: 22036839.
  • Grände PO. The Lund concept for the treatment of patients with severe traumatic brain injury. J Neurosurg Anesthesiol. 2011 Oct;23(4):358-62. doi: 10.1097/01.ana.0000405612.20356.84. Review. PubMed PMID: 21908989.
  • Nordström CH. Physiological and biochemical principles underlying volume-targeted therapy–the “Lund concept”. Neurocrit Care. 2005;2(1):83-95. Review. PubMed PMID: 16174975.
  • Sharma D, Vavilala MS. Lund concept for the management of traumatic brain injury: a physiological principle awaiting stronger evidence. J Neurosurg Anesthesiol. 2011 Oct;23(4):363-7. doi: 10.1097/01.ana.0000405613.27980.ea. Review. PubMed PMID: 21908990.

Share this:

  • Facebook
  • LinkedIn
  • Twitter

About Chris Nickson

FCICM FACEM BSc(Hons) BHB MBChB MClinEpid(ClinTox) DipPaeds DTM&H GCertClinSim

Chris is an Intensivist at the Alfred ICU in Melbourne and is an Adjunct Clinical Associate Professor at Monash University. He is also the Innovation Lead for the Australian Centre for Health Innovation and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He has a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. He coordinates the Alfred ICU's education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the 'Critically Ill Airway' course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of Lifeinthefastlane.com, the RAGE podcast, the Resuscitology course, and the SMACC conference. His one great achievement is being the father of two amazing children. On Twitter, he is @precordialthump.

Reader Interactions

Comments

  1. Chris Nickson says

    June 18, 2013 at 1:58 pm

    Grande Lund Concept
    http://www.ncbi.nlm.nih.gov/pubmed/16896859

    Interview with Grande
    http://www.intensive.org/ISICEM_News/Traumatic%20brain%20injury.pdf

    Reply

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Primary Sidebar

All LITFL posts by EMAIL or RSS

LITFL Weekly review by EMAIL or RSS

Frivolous Friday Five by EMAIL or RSS

Copyright © 2007 - 2019 · Powered by vocortex and iSimulate

We use cookies to understand site usage and to improve the content and offerings on our sites. If you continue using our website, we'll assume that you are happy to receive all cookies on this website.