1
|
Ramos MB, Britz JPE, Telles JPM, Nager GB, Cenci GI, Rynkowski CB, Teixeira MJ, Figueiredo EG. The Effects of Head Elevation on Intracranial Pressure, Cerebral Perfusion Pressure, and Cerebral Oxygenation Among Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2024:10.1007/s12028-024-02020-3. [PMID: 38886326 DOI: 10.1007/s12028-024-02020-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 05/23/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Head elevation is recommended as a tier zero measure to decrease high intracranial pressure (ICP) in neurocritical patients. However, its quantitative effects on cerebral perfusion pressure (CPP), jugular bulb oxygen saturation (SjvO2), brain tissue partial pressure of oxygen (PbtO2), and arteriovenous difference of oxygen (AVDO2) are uncertain. Our objective was to evaluate the effects of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2 among patients with acute brain injury. METHODS We conducted a systematic review and meta-analysis on PubMed, Scopus, and Cochrane Library of studies comparing the effects of different degrees of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2. RESULTS A total of 25 articles were included in the systematic review. Of these, 16 provided quantitative data regarding outcomes of interest and underwent meta-analyses. The mean ICP of patients with acute brain injury was lower in group with 30° of head elevation than in the supine position group (mean difference [MD] - 5.58 mm Hg; 95% confidence interval [CI] - 6.74 to - 4.41 mm Hg; p < 0.00001). The only comparison in which a greater degree of head elevation did not significantly reduce the ICP was 45° vs. 30°. The mean CPP remained similar between 30° of head elevation and supine position (MD - 2.48 mm Hg; 95% CI - 5.69 to 0.73 mm Hg; p = 0.13). Similar findings were observed in all other comparisons. The mean SjvO2 was similar between the 30° of head elevation and supine position groups (MD 0.32%; 95% CI - 1.67% to 2.32%; p = 0.75), as was the mean PbtO2 (MD - 1.50 mm Hg; 95% CI - 4.62 to 1.62 mm Hg; p = 0.36), and the mean AVDO2 (MD 0.06 µmol/L; 95% CI - 0.20 to 0.32 µmol/L; p = 0.65).The mean ICP of patients with traumatic brain injury was also lower with 30° of head elevation when compared to the supine position. There was no difference in the mean values of mean arterial pressure, CPP, SjvO2, and PbtO2 between these groups. CONCLUSIONS Increasing degrees of head elevation were associated, in general, with a lower ICP, whereas CPP and brain oxygenation parameters remained unchanged. The severe traumatic brain injury subanalysis found similar results.
Collapse
Affiliation(s)
- Miguel Bertelli Ramos
- Department Neurosurgery, Hospital Do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - João Pedro Einsfeld Britz
- Department of Neurosurgery, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | | | - Gabriela Borges Nager
- School of Medicine, Universidade Federal Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | |
Collapse
|
2
|
Salvagno M, Geraldini F, Coppalini G, Robba C, Gouvea Bogossian E, Annoni F, Vitali E, Sterchele ED, Balestra C, Taccone FS. The Impact of Inotropes and Vasopressors on Cerebral Oxygenation in Patients with Traumatic Brain Injury and Subarachnoid Hemorrhage: A Narrative Review. Brain Sci 2024; 14:117. [PMID: 38391692 PMCID: PMC10886736 DOI: 10.3390/brainsci14020117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 01/17/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) are critical neurological conditions that necessitate specialized care in the Intensive Care Unit (ICU). Managing cerebral perfusion pressure (CPP) and mean arterial pressure (MAP) is of primary importance in these patients. To maintain targeted MAP and CPP, vasopressors and/or inotropes are commonly used. However, their effects on cerebral oxygenation are not fully understood. The aim of this review is to provide an up-to date review regarding the current uses and pathophysiological issues related to the use of vasopressors and inotropes in TBI and SAH patients. According to our findings, despite achieving similar hemodynamic parameters and CPP, the effects of various vasopressors and inotropes on cerebral oxygenation, local CBF and metabolism are heterogeneous. Therefore, a more accurate understanding of the cerebral activity of these medications is crucial for optimizing patient management in the ICU setting.
Collapse
Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Federico Geraldini
- Department of Anesthesia and Intensive Care, Ospedale Università di Padova, 35128 Padova, Italy
| | - Giacomo Coppalini
- Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Center, 20089 Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milano, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS Policlinico San Martino, 16132 Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, Università di Genova, 16132 Genova, Italy
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Eva Vitali
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Elda Diletta Sterchele
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| | - Costantino Balestra
- Department Environmental, Occupational, Aging (Integrative) Physiology Laboratory, Haute Ecole Bruxelles-Brabant (HE2B), 1160 Brussels, Belgium
- Anatomical Research and Clinical Studies, Vrije Universiteit Brussels (VUB), 1090 Brussels, Belgium
- DAN Europe Research Division (Roseto-Brussels), 1160 Brussels, Belgium
- Motor Sciences Department, Physical Activity Teaching Unit, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), 1070 Brussels, Belgium
| |
Collapse
|
3
|
O'Donnell JC, Browne KD, Kvint S, Makaron L, Grovola MR, Karandikar S, Kilbaugh TJ, Cullen DK, Petrov D. Multimodal Neuromonitoring and Neurocritical Care in Swine to Enhance Translational Relevance in Brain Trauma Research. Biomedicines 2023; 11:biomedicines11051336. [PMID: 37239007 DOI: 10.3390/biomedicines11051336] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Neurocritical care significantly impacts outcomes after moderate-to-severe acquired brain injury, but it is rarely applied in preclinical studies. We created a comprehensive neurointensive care unit (neuroICU) for use in swine to account for the influence of neurocritical care, collect clinically relevant monitoring data, and create a paradigm that is capable of validating therapeutics/diagnostics in the unique neurocritical care space. Our multidisciplinary team of neuroscientists, neurointensivists, and veterinarians adapted/optimized the clinical neuroICU (e.g., multimodal neuromonitoring) and critical care pathways (e.g., managing cerebral perfusion pressure with sedation, ventilation, and hypertonic saline) for use in swine. Moreover, this neurocritical care paradigm enabled the first demonstration of an extended preclinical study period for moderate-to-severe traumatic brain injury with coma beyond 8 h. There are many similarities with humans that make swine an ideal model species for brain injury studies, including a large brain mass, gyrencephalic cortex, high white matter volume, and topography of basal cisterns, amongst other critical factors. Here we describe the neurocritical care techniques we developed and the medical management of swine following subarachnoid hemorrhage and traumatic brain injury with coma. Incorporating neurocritical care in swine studies will reduce the translational gap for therapeutics and diagnostics specifically tailored for moderate-to-severe acquired brain injury.
Collapse
Affiliation(s)
- John C O'Donnell
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin D Browne
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Svetlana Kvint
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Leah Makaron
- University Laboratory Animal Resources, Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Michael R Grovola
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Saarang Karandikar
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Todd J Kilbaugh
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - D Kacy Cullen
- Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA 19104, USA
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dmitriy Petrov
- Center for Brain Injury & Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
4
|
Hays LM, Udy A, Adamides AA, Anstey JR, Bailey M, Bellapart J, Byrne K, Cheng A, Jamie Cooper D, Drummond KJ, Haenggi M, Jakob SM, Higgins AM, Lewis PM, Hunn MK, McNamara R, Menon DK, Murray L, Reddi B, Trapani T, Vallance S, Young PJ, Diaz-Arrastia R, Shutter L, Murray PT, Curley GF, Nichol A. Effects of brain tissue oxygen (PbtO2) guided management on patient outcomes following severe traumatic brain injury: A systematic review and meta-analysis. J Clin Neurosci 2022; 99:349-358. [DOI: 10.1016/j.jocn.2022.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022]
|
5
|
Kovacs M, Peluso L, Njimi H, De Witte O, Gouvêa Bogossian E, Quispe Cornejo A, Creteur J, Schuind S, Taccone FS. Optimal Cerebral Perfusion Pressure Guided by Brain Oxygen Pressure Measurement. Front Neurol 2021; 12:732830. [PMID: 34777201 PMCID: PMC8581172 DOI: 10.3389/fneur.2021.732830] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Although increasing cerebral perfusion pressure (CPP) is commonly accepted to improve brain tissue oxygen pressure (PbtO2), it remains unclear whether recommended CPP targets (i. e., >60 mmHg) would result in adequate brain oxygenation in brain injured patients. The aim of this study was to identify the target of CPP associated with normal brain oxygenation. Methods: Prospectively collected data including patients suffering from acute brain injury and monitored with PbtO2, in whom daily CPP challenge using vasopressors was performed. Initial CPP target was >60 mmHg; norepinephrine infusion was modified to have an increase in CPP of at least 10 mmHg at two different steps above the baseline values. Whenever possible, the same CPP challenge was performed for the following days, for a maximum of 5 days. CPP “responders” were patients with a relative increase in PbtO2 from baseline values > 20%. Results: A total of 53 patients were included. On the first day of assessment, CPP was progressively increased from 73 (70–76) to 83 (80–86), and 92 (90–96) mmHg, which resulted into a significant PbtO2 increase [from 20 (17–23) mmHg to 22 (20–24) mmHg and 24 (22–26) mmHg, respectively; p < 0.001]. Median CPP value corresponding to PbtO2 values > 20 mmHg was 79 (74–87) mmHg, with 2 (4%) patients who never achieved such target. Similar results of CPP targets were observed the following days. A total of 25 (47%) were PbtO2 responders during the CPP challenge on day 1, in particular if low PbtO2 was observed at baseline. Conclusions: PbtO2 monitoring can be an effective way to individualize CPP values to avoid tissue hypoxia. Low PbtO2 values at baseline can identify the responders to the CPP challenge.
Collapse
Affiliation(s)
- Matyas Kovacs
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Hassane Njimi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier De Witte
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Armin Quispe Cornejo
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Sophie Schuind
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
6
|
Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
Collapse
Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
| |
Collapse
|
7
|
Eun J, Huh J, Yang SY, Huh HY, Ahn JK, Cho KW, Kim YW, Kim SL, Kim JT, Yoo DS, Park HK, Ji C. Determining the Lower Limit of Cerebral Perfusion Pressure in Patients Undergoing Decompressive Craniectomy Following Traumatic Brain Injury. World Neurosurg 2017; 111:e32-e39. [PMID: 29203313 DOI: 10.1016/j.wneu.2017.11.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), maintaining systolic blood pressure >90 mm Hg, intracranial pressure (ICP) <20 mm Hg and cerebral perfusion pressure (CPP) >60-70 mm Hg is recommended to improve clinical outcomes. A recommended CPP value for patients treated with decompressive craniectomy (DC) has not been clearly studied. We aimed to determine whether the targeted CPP can be lowered in patients treated with DC. METHODS This retrospective analysis included 191 patients who underwent DC for TBI. All patients were monitored for ICP and blood pressure during and after DC. CPP was calculated every 2 hours after DC. Patient outcomes were evaluated 6 months after initial treatment. RESULTS Mean patient age was 50.8 years (median 52 years), and 79.1% of patients were male. Initial Glasgow Coma Scale score was 6.2 (median 6). Comparing clinical outcome based on postoperative ICP >25 mm Hg and <25 mm Hg, Extended Glasgow Outcome Scale score was 1.4 (>25 mm Hg) and 4.9 (<25 mm Hg) (P = 0.000). In patients maintained at ICP <25 mm Hg, mortality was increased significantly with CPP between 35 mmHg and 30 mm Hg (χ2, P = 0.029 vs. P = 0.062). CONCLUSIONS Patients with TBI who underwent DC with postoperative ICP maintained <25 mm Hg and CPP >35 mm Hg may have similar mortality as patients with CPP >60-70 mm Hg who did not undergo DC. For patients with TBI who undergo DC, targeted CPP might be lowered to 35 mm Hg if ICP is maintained <25 mm Hg.
Collapse
Affiliation(s)
- Jin Eun
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Joon Huh
- Department of Neurosurgery, Myungji St. Mary's Hospital, Seoul, Republic of Korea
| | - Seo-Yeon Yang
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Han-Yong Huh
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae-Kun Ahn
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Kwang-Wook Cho
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Young-Woo Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Sung-Lim Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Jong-Tae Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Incheon, Republic of Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea; Department of Neurosurgery, Uijongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea.
| | - Hae-Kwan Park
- Department of Neurosurgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Cheol Ji
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
8
|
Okonkwo DO, Shutter LA, Moore C, Temkin NR, Puccio AM, Madden CJ, Andaluz N, Chesnut RM, Bullock MR, Grant GA, McGregor J, Weaver M, Jallo J, LeRoux PD, Moberg D, Barber J, Lazaridis C, Diaz-Arrastia RR. Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: A Phase II Randomized Trial. Crit Care Med 2017; 45:1907-1914. [PMID: 29028696 PMCID: PMC5679063 DOI: 10.1097/ccm.0000000000002619] [Citation(s) in RCA: 279] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A relationship between reduced brain tissue oxygenation and poor outcome following severe traumatic brain injury has been reported in observational studies. We designed a Phase II trial to assess whether a neurocritical care management protocol could improve brain tissue oxygenation levels in patients with severe traumatic brain injury and the feasibility of a Phase III efficacy study. DESIGN Randomized prospective clinical trial. SETTING Ten ICUs in the United States. PATIENTS One hundred nineteen severe traumatic brain injury patients. INTERVENTIONS Patients were randomized to treatment protocol based on intracranial pressure plus brain tissue oxygenation monitoring versus intracranial pressure monitoring alone. Brain tissue oxygenation data were recorded in the intracranial pressure -only group in blinded fashion. Tiered interventions in each arm were specified and impact on intracranial pressure and brain tissue oxygenation measured. Monitors were removed if values were normal for 48 hours consecutively, or after 5 days. Outcome was measured at 6 months using the Glasgow Outcome Scale-Extended. MEASUREMENTS AND MAIN RESULTS A management protocol based on brain tissue oxygenation and intracranial pressure monitoring reduced the proportion of time with brain tissue hypoxia after severe traumatic brain injury (0.45 in intracranial pressure-only group and 0.16 in intracranial pressure plus brain tissue oxygenation group; p < 0.0001). Intracranial pressure control was similar in both groups. Safety and feasibility of the tiered treatment protocol were confirmed. There were no procedure-related complications. Treatment of secondary injury after severe traumatic brain injury based on brain tissue oxygenation and intracranial pressure values was consistent with reduced mortality and increased proportions of patients with good recovery compared with intracranial pressure-only management; however, the study was not powered for clinical efficacy. CONCLUSIONS Management of severe traumatic brain injury informed by multimodal intracranial pressure and brain tissue oxygenation monitoring reduced brain tissue hypoxia with a trend toward lower mortality and more favorable outcomes than intracranial pressure-only treatment. A Phase III randomized trial to assess impact on neurologic outcome of intracranial pressure plus brain tissue oxygenation-directed treatment of severe traumatic brain injury is warranted.
Collapse
Affiliation(s)
- David O Okonkwo
- 1University of Pittsburgh School of Medicine, Pittsburgh, PA. 2Uniformed Services University of the Health Sciences, Bethesda, MD. 3University of Washington, Seattle, WA. 4UT Southwestern Medical Center, Dallas, TX. 5University of Cincinnati College of Medicine, Cincinnati, OH. 6University of Miami, Miller School of Medicine, Miami, FL. 7Stanford University, Stanford, CA. 8Ohio State University College of Medicine, Columbus, OH. 9Temple University, Philadelphia, PA. 10Thomas Jefferson University, Philadelphia, PA. 11Lankenau Medical Center, Wynnewood, PA. 12Moberg Research, Ambler, PA. 13Baylor St. Luke's Medical Center, Houston, TX. 14Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Benefit on optimal cerebral perfusion pressure targeted treatment for traumatic brain injury patients. J Crit Care 2017; 41:49-55. [PMID: 28477510 DOI: 10.1016/j.jcrc.2017.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 04/02/2017] [Accepted: 04/20/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE The maintenance of patient-specific optimal cerebral perfusion pressure (CPPopt) is crucial for patients with traumatic brain injury (TBI). The goal of the study was to explore the influence of CPP declination from CPPopt value on the TBI patients' outcome. METHODS The CPP and cerebrovascular autoregulation (CA) monitoring of 52 TBI patients was performed. Patient-specific CPPopt has been identified and the associations between the patients' outcome and complex influence of time of CPP declination from CPPopt value, age, and the duration of CA impairment episodes has been analyzed. RESULTS The multiple correlation coefficient between the Glasgow outcome scale (GOS), duration of CA impairment events and percentage time, when 0<ΔCPPopt<10mmHg was r=-0.643 (P<0.001). The multiple correlation coefficients between GOS, age, and percentage time of ΔCPPopt when 0<ΔCPPopt<10mmHg was r=-0.587 (P<0.001). CONCLUSION The CPPopt-targeted patient-specific management might be useful for stabilizing CA in TBI patients as well as for improving their outcome. Better outcomes were obtained by maintaining CPP in light hyperperfusion condition (up to 10mmHg above CPPopt) when CPPopt is in the range of 60-80mmHg, and keeping CPP within the range of CPPopt +/-5mmHg when CPPopt is above 80mmHg.
Collapse
|
10
|
Seifter JL, Chang HY. Disorders of Acid-Base Balance: New Perspectives. KIDNEY DISEASES (BASEL, SWITZERLAND) 2017; 2:170-186. [PMID: 28232934 PMCID: PMC5260542 DOI: 10.1159/000453028] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/26/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Disorders of acid-base involve the complex interplay of many organ systems including brain, lungs, kidney, and liver. Compensations for acid-base disturbances within the brain are more complete, while limitations of compensations are more apparent for most systemic disorders. However, some of the limitations on compensations are necessary to survival, in that preservation of oxygenation, energy balance, cognition, electrolyte, and fluid balance are connected mechanistically. SUMMARY This review aims to give new and comprehensive perspective on understanding acid-base balance and identifying associated disorders. All metabolic acid-base disorders can be approached in the context of the relative losses or gains of electrolytes or a change in the anion gap in body fluids. Acid-base and electrolyte balance are connected not only at the cellular level but also in daily clinical practice. Urine chemistry is essential to understanding electrolyte excretion and renal compensations. KEY MESSAGES Many constructs are helpful to understand acid-base, but these models are not mutually exclusive. Electroneutrality and the close interconnection between electrolyte and acid-base balance are important concepts to apply in acid-base diagnoses. All models have complexity and shortcuts that can help in practice. There is no reason to dismiss any of the present constructs, and there is benefit in a combined approach.
Collapse
Affiliation(s)
- Julian L. Seifter
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hsin-Yun Chang
- Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| |
Collapse
|
11
|
Abstract
Since traumatic brain injury is the most common cause of long-term disability and death among young adults, it represents an enormous socio-economic and healthcare burden. As a consequence of the primary lesion, a perifocal brain edema develops causing an elevation of the intracranial pressure due to the limited intracranial space. This entails a reduction of the cerebral perfusion pressure and the cerebral blood flow. A cerebral perfusion deficit below the threshold for ischemia leads to further ischemic lesions and to a progression of the contusion. As the irreversible primary lesion can only be inhibited by primary prevention, the therapy of traumatic brain injury focuses on the secondary injuries. The treatment consists of surgical therapy evacuating the space-occupying intracranial lesion and conservative intensive medical care. Due to the complex pathophysiology the therapy of traumatic brain injury should be rapidly performed in a neurosurgical unit.
Collapse
|
12
|
Hawryluk GWJ, Phan N, Ferguson AR, Morabito D, Derugin N, Stewart CL, Knudson MM, Manley G, Rosenthal G. Brain tissue oxygen tension and its response to physiological manipulations: influence of distance from injury site in a swine model of traumatic brain injury. J Neurosurg 2016; 125:1217-1228. [PMID: 26848909 DOI: 10.3171/2015.7.jns15809] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal site for placement of tissue oxygen probes following traumatic brain injury (TBI) remains unresolved. The authors used a previously described swine model of focal TBI and studied brain tissue oxygen tension (PbtO2) at the sites of contusion, proximal and distal to contusion, and in the contralateral hemisphere to determine the effect of probe location on PbtO2 and to assess the effects of physiological interventions on PbtO2 at these different sites. METHODS A controlled cortical impact device was used to generate a focal lesion in the right frontal lobe in 12 anesthetized swine. PbtO2 was measured using Licox brain tissue oxygen probes placed at the site of contusion, in pericontusional tissue (proximal probe), in the right parietal region (distal probe), and in the contralateral hemisphere. PbtO2 was measured during normoxia, hyperoxia, hypoventilation, and hyperventilation. RESULTS Physiological interventions led to expected changes, including a large increase in partial pressure of oxygen in arterial blood with hyperoxia, increased intracranial pressure (ICP) with hypoventilation, and decreased ICP with hyperventilation. Importantly, PbtO2 decreased substantially with proximity to the focal injury (contusion and proximal probes), and this difference was maintained at different levels of fraction of inspired oxygen and partial pressure of carbon dioxide in arterial blood. In the distal and contralateral probes, hypoventilation and hyperventilation were associated with expected increased and decreased PbtO2 values, respectively. However, in the contusion and proximal probes, these effects were diminished, consistent with loss of cerebrovascular CO2 reactivity at and near the injury site. Similarly, hyperoxia led to the expected rise in PbtO2 only in the distal and contralateral probes, with little or no effect in the proximal and contusion probes, respectively. CONCLUSIONS PbtO2 measurements are strongly influenced by the distance from the site of focal injury. Physiological alterations, including hyperoxia, hyperventilation, and hypoventilation substantially affect PbtO2 values distal to the site of injury but have little effect in and around the site of contusion. Clinical interpretations of brain tissue oxygen measurements should take into account the spatial relation of probe position to the site of injury. The decision of where to place a brain tissue oxygen probe in TBI patients should also take these factors into consideration.
Collapse
Affiliation(s)
- Gregory W J Hawryluk
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah.,Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Nicolas Phan
- Brain and Spinal Injury Center, and.,Division of Neurological Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adam R Ferguson
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Diane Morabito
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Nikita Derugin
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Campbell L Stewart
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - M Margaret Knudson
- Department of General Surgery, University of California, San Francisco, California
| | - Geoffrey Manley
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Guy Rosenthal
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and.,Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
13
|
Abstract
OBJECTIVES Based on evidence supporting a potential relation between posttraumatic brain hypoxia and microcirculatory derangements with cell edema, we investigated the effects of the antiedematous agent mannitol on brain tissue oxygenation in a model of diffuse traumatic brain injury. DESIGN Experimental study. SETTING Neurosciences and physiology laboratories. SUBJECTS Adult male Wistar rats. INTERVENTIONS Thirty minutes after diffuse traumatic brain injury (impact-acceleration model), rats were IV administered with either a saline solution (traumatic brain injury-saline group) or 20% mannitol (1 g/kg) (traumatic brain injury-mannitol group). Sham-saline and sham-mannitol groups received no insult. MEASUREMENTS AND MAIN RESULTS Two series of experiments were conducted 2 hours after traumatic brain injury (or equivalent) to investigate 1) the effect of mannitol on brain edema and oxygenation, using a multiparametric magnetic resonance-based approach (n = 10 rats per group) to measure the apparent diffusion coefficient, tissue oxygen saturation, mean transit time, and blood volume fraction in the cortex and caudoputamen; 2) the effect of mannitol on brain tissue PO2 and on venous oxygen saturation of the superior sagittal sinus (n = 5 rats per group); and 3) the cortical ultrastructural changes after treatment (n = 1 per group, taken from the first experiment). Compared with the sham-saline group, the traumatic brain injury-saline group had significantly lower tissue oxygen saturation, brain tissue PO2, and venous oxygen saturation of the superior sagittal sinus values concomitant with diffuse brain edema. These effects were associated with microcirculatory collapse due to astrocyte swelling. Treatment with mannitol after traumatic brain injury reversed all these effects. In the absence of traumatic brain injury, mannitol had no effect on brain oxygenation. Mean transit time and blood volume fraction were comparable between the four groups of rats. CONCLUSION The development of posttraumatic brain edema can limit the oxygen utilization by brain tissue without evidence of brain ischemia. Our findings indicate that an antiedematous agent such as mannitol can improve brain tissue oxygenation, possibly by limiting astrocyte swelling and restoring capillary perfusion.
Collapse
|
14
|
A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients. BIOMED RESEARCH INTERNATIONAL 2015; 2015:529580. [PMID: 26413530 PMCID: PMC4564619 DOI: 10.1155/2015/529580] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 04/14/2015] [Accepted: 04/15/2015] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to compare the effect of PbtO2-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale <12 were recruited from 6 collaborative hospitals in northern Taiwan, excluding patients with severe systemic injuries, fixed and dilated pupils, and other major diseases. In total, 23 patients were treated with PbtO2-guided management (PbtO2 > 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO2-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO2 signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO2 monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO2 to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma.
Collapse
|
15
|
Narotam PK, Morrison JF, Schmidt MD, Nathoo N. Physiological complexity of acute traumatic brain injury in patients treated with a brain oxygen protocol: utility of symbolic regression in predictive modeling of a dynamical system. J Neurotrauma 2014; 31:630-41. [PMID: 24195645 DOI: 10.1089/neu.2013.3104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Predictive modeling of emergent behavior, inherent to complex physiological systems, requires the analysis of large complex clinical data streams currently being generated in the intensive care unit. Brain tissue oxygen protocols have yielded outcome benefits in traumatic brain injury (TBI), but the critical physiological thresholds for low brain oxygen have not been established for a dynamical patho-physiological system. High frequency, multi-modal clinical data sets from 29 patients with severe TBI who underwent multi-modality neuro-clinical care monitoring and treatment with a brain oxygen protocol were analyzed. The inter-relationship between acute physiological parameters was determined using symbolic regression (SR) as the computational framework. The mean patient age was 44.4±15 with a mean admission GCS of 6.6±3.9. Sixty-three percent sustained motor vehicle accidents and the most common pathology was intra-cerebral hemorrhage (50%). Hospital discharge mortality was 21%, poor outcome occurred in 24% of patients, and good outcome occurred in 56% of patients. Criticality for low brain oxygen was intracranial pressure (ICP) ≥22.8 mm Hg, for mortality at ICP≥37.1 mm Hg. The upper therapeutic threshold for cerebral perfusion pressure (CPP) was 75 mm Hg. Eubaric hyperoxia significantly impacted partial pressure of oxygen in brain tissue (PbtO2) at all ICP levels. Optimal brain temperature (Tbr) was 34-35°C, with an adverse effect when Tbr≥38°C. Survivors clustered at [Formula: see text] Hg vs. non-survivors [Formula: see text] 18 mm Hg. There were two mortality clusters for ICP: High ICP/low PbtO2 and low ICP/low PbtO2. Survivors maintained PbtO2 at all ranges of mean arterial pressure in contrast to non-survivors. The final SR equation for cerebral oxygenation is: [Formula: see text]. The SR-model of acute TBI advances new physiological thresholds or boundary conditions for acute TBI management: PbtO2≥25 mmHg; ICP≤22 mmHg; CPP≈60-75 mmHg; and Tbr≈34-37°C. SR is congruous with the emerging field of complexity science in the modeling of dynamical physiological systems, especially during pathophysiological states. The SR model of TBI is generalizable to known physical laws. This increase in entropy reduces uncertainty and improves predictive capacity. SR is an appropriate computational framework to enable future smart monitoring devices.
Collapse
|
16
|
Kim JE, Ko SB, Kang HS, Seo DH, Park SQ, Sheen SH, Park HS, Kang SD, Kim JM, Oh CW, Hong KS, Yu KH, Heo JH, Kwon SU, Bae HJ, Lee BC, Yoon BW, Park IS, Rha JH. Clinical practice guidelines for the medical and surgical management of primary intracerebral hemorrhage in Korea. J Korean Neurosurg Soc 2014; 56:175-87. [PMID: 25368758 PMCID: PMC4217052 DOI: 10.3340/jkns.2014.56.3.175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/15/2014] [Accepted: 09/06/2014] [Indexed: 12/03/2022] Open
Abstract
The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.
Collapse
Affiliation(s)
- Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Hee Seo
- Department of Neurosurgery, Good Morning Hospital, Pyeongtaek, Korea
| | - Sukh-Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun Sun Park
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Sung Don Kang
- Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University College of Medicine, Guri, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University College of Medicine, Goyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Uck Kwon
- Department of Neurology, University of Ulsan College of Medicine, Seoul, Koera
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Incheon, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University College of Medicine, Incheon, Korea
| |
Collapse
|
17
|
Jeon SB, Koh Y, Choi HA, Lee K. Critical care for patients with massive ischemic stroke. J Stroke 2014; 16:146-60. [PMID: 25328873 PMCID: PMC4200590 DOI: 10.5853/jos.2014.16.3.146] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 01/29/2023] Open
Abstract
Malignant cerebral edema following ischemic stroke is life threatening, as it can cause inadequate blood flow and perfusion leading to irreversible tissue hypoxia and metabolic crisis. Increased intracranial pressure and brain shift can cause herniation syndrome and finally brain death. Multiple randomized clinical trials have shown that preemptive decompressive hemicraniectomy effectively reduces mortality and morbidity in patients with malignant middle cerebral artery infarction. Another life-saving decompressive surgery is suboccipital craniectomy for patients with brainstem compression by edematous cerebellar infarction. In addition to decompressive surgery, cerebrospinal fluid drainage by ventriculostomy should be considered for patients with acute hydrocephalus following stroke. Medical treatment begins with sedation, analgesia, and general measures including ventilatory support, head elevation, maintaining a neutral neck position, and avoiding conditions associated with intracranial hypertension. Optimization of cerebral perfusion pressure and reduction of intracranial pressure should always be pursued simultaneously. Osmotherapy with mannitol is the standard treatment for intracranial hypertension, but hypertonic saline is also an effective alternative. Therapeutic hypothermia may also be considered for treatment of brain edema and intracranial hypertension, but its neuroprotective effects have not been demonstrated in stroke. Barbiturate coma therapy has been used to reduce metabolic demand, but has become less popular because of its systemic adverse effects. Furthermore, general medical care is critical because of the complex interactions between the brain and other organ systems. Some challenging aspects of critical care, including ventilator support, sedation and analgesia, and performing neurological examinations in the setting of a minimal stimulation protocol, are addressed in this review.
Collapse
Affiliation(s)
- Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - H Alex Choi
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
| | - Kiwon Lee
- Departments of Neurology and Neurosurgery, The University of Texas Medical School at Houston, Houston, Texas, USA
| |
Collapse
|
18
|
Prabhakar H, Sandhu K, Bhagat H, Durga P, Chawla R. Current concepts of optimal cerebral perfusion pressure in traumatic brain injury. J Anaesthesiol Clin Pharmacol 2014; 30:318-27. [PMID: 25190937 PMCID: PMC4152669 DOI: 10.4103/0970-9185.137260] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO2), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.
Collapse
Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, PGIMER, Chandigarh, India
| | - Kavita Sandhu
- Department of Neuroanaesthesiology and Critical Care, Max Superspeciality Hospital, PGIMER, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Padmaja Durga
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Rajiv Chawla
- Department of Anaesthesiology and Intensive Care, G B Pant Hospital, New Delhi, India
| |
Collapse
|
19
|
Spaite DW, Bobrow BJ, Stolz U, Sherrill D, Chikani V, Barnhart B, Sotelo M, Gaither JB, Viscusi C, Adelson PD, Denninghoff KR. Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology. Acad Emerg Med 2014; 21:818-30. [PMID: 25112451 PMCID: PMC4134700 DOI: 10.1111/acem.12411] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/18/2014] [Accepted: 02/28/2014] [Indexed: 11/28/2022]
Abstract
Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.
Collapse
Affiliation(s)
- Daniel W Spaite
- The Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Tucson, AZ; The Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Hardcastle N, Benzon HA, Vavilala MS. Update on the 2012 guidelines for the management of pediatric traumatic brain injury - information for the anesthesiologist. Paediatr Anaesth 2014; 24:703-10. [PMID: 24815014 PMCID: PMC4146616 DOI: 10.1111/pan.12415] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2014] [Indexed: 01/05/2023]
Abstract
Traumatic brain injury (TBI) is a significant contributor to death and disability in children. Considering the prevalence of pediatric TBI, it is important for the clinician to be aware of evidence-based recommendations for the care of these patients. The first edition of the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents was published in 2003. The Guidelines were updated in 2012, with significant changes in the recommendations for hyperosmolar therapy, temperature control, hyperventilation, corticosteroids, glucose therapy, and seizure prophylaxis. Many of these interventions have implications in the perioperative period, and it is the responsibility of the anesthesiologist to be familiar with these guidelines.
Collapse
Affiliation(s)
- Nina Hardcastle
- Department of Pediatric Anesthesiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Hubert A. Benzon
- Department of Pediatric Anesthesiology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Monica S. Vavilala
- Department of Pediatric Anesthesiology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA, USA
- Department of Anesthesiology and Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
21
|
Vinas FC, Verweij BH, Muizelaar JP. Invasive monitoring of cerebral oxygenation. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s003290050058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
22
|
De Georgia MA. Brain Tissue Oxygen Monitoring in Neurocritical Care. J Intensive Care Med 2014; 30:473-83. [PMID: 24710714 DOI: 10.1177/0885066614529254] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/14/2014] [Indexed: 11/15/2022]
Abstract
Brain injury results from ischemia, tissue hypoxia, and a cascade of secondary events. The cornerstone of neurocritical care management is optimization and maintenance of cerebral blood flow (CBF) and oxygen and substrate delivery to prevent or attenuate this secondary damage. New techniques for monitoring brain tissue oxygen tension (PtiO2) are now available. Brain PtiO2 reflects both oxygen delivery and consumption. Brain hypoxia (low brain PtiO2) has been associated with poor outcomes in patients with brain injury. Strategies to improve brain PtiO2 have focused mainly on increasing oxygen delivery either by increasing CBF or by increasing arterial oxygen content. The results of nonrandomized studies comparing brain PtiO2-guided therapy with intracranial pressure/cerebral perfusion pressure-guided therapy, while promising, have been mixed. More studies are needed including prospective, randomized controlled trials to assess the true value of this approach. The following is a review of the physiology of brain tissue oxygenation, the effect of brain hypoxia on outcome, strategies to increase oxygen delivery, and outcome studies of brain PtiO2-guided therapy in neurocritical care.
Collapse
Affiliation(s)
- Michael A De Georgia
- Case Western Reserve University School of Medicine, Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH, USA
| |
Collapse
|
23
|
Kosty JA, LeRoux PD, Levine J, Park S, Kumar MA, Frangos S, Maloney-Wilensky E, Kofke WA. A Comparison of Clinical and Research Practices in Measuring Cerebral Perfusion Pressure. Anesth Analg 2013; 117:694-698. [DOI: 10.1213/ane.0b013e31829cc765] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
24
|
Balancing the Potential Risks and Benefits of Out-of-Hospital Intubation in Traumatic Brain Injury: The Intubation/Hyperventilation Effect. Ann Emerg Med 2012; 60:732-6. [DOI: 10.1016/j.annemergmed.2012.06.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 06/11/2012] [Accepted: 06/25/2012] [Indexed: 11/20/2022]
|
25
|
Abstract
OBJECTIVES We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPPopt algorithm by determining the association between outcome and the deviation of actual CPP from CPPopt. DESIGN Retrospective analysis of prospectively collected data. SETTING Neurosciences critical care unit of a university hospital. PATIENTS A total of 327 traumatic head-injury patients admitted between 2003 and 2009 with continuous monitoring of arterial blood pressure and intracranial pressure. MEASUREMENTS AND MAIN RESULTS Arterial blood pressure, intracranial pressure, and CPP were continuously recorded, and pressure reactivity index was calculated online. Outcome was assessed at 6 months. An automated curve fitting method was applied to determine CPP at the minimum value for pressure reactivity index (CPPopt). A time trend of CPPopt was created using a moving 4-hr window, updated every minute. Identification of CPPopt was, on average, feasible during 55% of the whole recording period. Patient outcome correlated with the continuously updated difference between median CPP and CPPopt (chi-square=45, p<.001; outcome dichotomized into fatal and nonfatal). Mortality was associated with relative "hypoperfusion" (CPP<CPPopt), severe disability with "hyperperfusion" (CPP>CPPopt), and favorable outcome was associated with smaller deviations of CPP from the individualized CPPopt. While deviations from global target CPP values of 60 mm Hg and 70 mm Hg were also related to outcome, these relationships were less robust. CONCLUSIONS Real-time CPPopt could be identified during the recording time of majority of the patients. Patients with a median CPP close to CPPopt were more likely to have a favorable outcome than those in whom median CPP was widely different from CPPopt. Deviations from individualized CPPopt were more predictive of outcome than deviations from a common target CPP. CPP management to optimize cerebrovascular pressure reactivity should be the subject of future clinical trial in severe traumatic head-injury patients.
Collapse
|
26
|
Beynon C, Kiening KL, Orakcioglu B, Unterberg AW, Sakowitz OW. Brain tissue oxygen monitoring and hyperoxic treatment in patients with traumatic brain injury. J Neurotrauma 2012; 29:2109-23. [PMID: 22616852 DOI: 10.1089/neu.2012.2365] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cerebral ischemia is a well-recognized contributor to high morbidity and mortality after traumatic brain injury (TBI). Standard of care treatment aims to maintain a sufficient oxygen supply to the brain by avoiding increased intracranial pressure (ICP) and ensuring a sufficient cerebral perfusion pressure (CPP). Devices allowing direct assessment of brain tissue oxygenation have showed promising results in clinical studies, and their use was implemented in the Brain Trauma Foundation Guidelines for the treatment of TBI patients in 2007. Results of several studies suggest that a brain tissue oxygen-directed therapy guided by these monitors may contribute to reduced mortality and improved outcome of TBI patients. Whether increasing the oxygen supply to supraphysiological levels has beneficial or detrimental effects on TBI patients has been a matter of debate for decades. The results of trials of hyperbaric oxygenation (HBO) have failed to show a benefit, but renewed interest in normobaric hyperoxia (NBO) in the treatment of TBI patients has emerged in recent years. With the increased availability of advanced neuromonitoring devices such as brain tissue oxygen monitors, it was shown that some patients might benefit from this therapeutic approach. In this article, we review the pathophysiological rationale and technical modalities of brain tissue oxygen monitors, as well as its use in studies of brain tissue oxygen-directed therapy. Furthermore, we analyze hyperoxia as a treatment option in TBI patients, summarize the results of clinical trials, and give insights into the recent findings of hyperoxic effects on cerebral metabolism after TBI.
Collapse
Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | | | | | | | | |
Collapse
|
27
|
Cerebral perfusion pressure and intracranial pressure are not surrogates for brain tissue oxygenation in traumatic brain injury. Clin Neurophysiol 2012; 123:1255-60. [DOI: 10.1016/j.clinph.2011.08.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 08/16/2011] [Accepted: 08/20/2011] [Indexed: 12/21/2022]
|
28
|
Stein DM, Lindell AL, Murdock KR, Kufera JA, Menaker J, Bochicchio GV, Aarabi B, Scalea TM. Use of serum biomarkers to predict cerebral hypoxia after severe traumatic brain injury. J Neurotrauma 2012; 29:1140-9. [PMID: 22360297 DOI: 10.1089/neu.2011.2149] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The management of severe traumatic brain injury (TBI) focuses on prevention and treatment of secondary insults such as cerebral hypoxia (CH). There are a number of biomarkers that are thought to play a part in secondary injury following severe TBI. This study evaluates the association between S100β, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), detected in the serum of severe TBI patients and CH as measured by brain tissue oxygen partial pressure (Pbo(2)). Patients with severe TBI were prospectively enrolled. Pressure times time (PTD; mm Hg*h), measuring the depth and duration of CH, was calculated for 12-h periods for episodes of moderate (Pbo(2) < 20 mm Hg) and severe (Pbo(2) < 15 mm Hg) CH, and compared to serum levels of S100β, NSE, and GFAP drawn prior to periods of monitoring. An adjusted mixed model analysis was applied as was receiver operating characteristic (ROC) curve analysis. Of 76 patients enrolled, 24 had Pbo(2) monitoring. One hundred and thirty serum samples were matched with 12-h periods of monitoring. Significant associations were found in adjusted analyses between increasing serum levels of S100β (coefficient=0.57, 0.56; p<0.001), NSE (coefficient=0.48, 0.52; p<0.001), and GFAP (coefficient=0.29, 0.30; p=0.003 and 0.002), and increasing PTD of moderate (Pbo(2)<20 mm Hg) and severe (Pbo(2)<15 mm Hg) CH. AUCs for the prediction of moderate and severe CH were 0.62 and 0.66 for S100β, 0.55 and 0.71 for NSE, and 0.50 and 0.62 for GFAP, respectively. Specificities were between 76% and 90% for S100β and NSE. S100β, NSE, and GFAP demonstrate promise as candidate serum markers of impending CH. The fact that these biomarker elevations occur prior to the onset of clinical manifestations suggests that we may be able to predict imminent events following TBI. Given the morbidity of CH, early intervention and prevention may have a significant impact on outcomes and help guide decisions about the timing of interventions.
Collapse
Affiliation(s)
- Deborah M Stein
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
Primary neurological injury in children can be induced by diverse intrinsic and extrinsic factors including brain trauma, tumors, and intracranial infections. Regardless of etiology, increased intracranial pressure (ICP) as a result of the primary injury or delays in treatment may lead to secondary (preventable) brain injury. Therefore, early diagnosis and aggressive treatment of increased ICP is vital in preventing or limiting secondary brain injury in children with a neurological insult. Present management strategies to improve survival and neurological outcome focus on reducing ICP while optimizing cerebral perfusion and meeting cerebral metabolic demands. Targeted therapies for increased ICP must be considered and implemented as early as possible during and after the initial stabilization of the child. Thus, the emergency physician has a critical role to play in early identification and treatment of increased ICP. This article intends to identify those patients at risk of intracranial hypertension and present a framework for the emergency department investigation and treatment, in keeping with contemporary guidelines. Intensive care management and the treatment of refractory increases in ICP are also outlined.
Collapse
|
30
|
|
31
|
Budohoski KP, Zweifel C, Kasprowicz M, Sorrentino E, Diedler J, Brady KM, Smielewski P, Menon DK, Pickard JD, Kirkpatrick PJ, Czosnyka M. What comes first? The dynamics of cerebral oxygenation and blood flow in response to changes in arterial pressure and intracranial pressure after head injury. Br J Anaesth 2012; 108:89-99. [PMID: 22037222 PMCID: PMC3236021 DOI: 10.1093/bja/aer324] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Brain tissue partial oxygen pressure (Pbt(O(2))) and near-infrared spectroscopy (NIRS) are novel methods to evaluate cerebral oxygenation. We studied the response patterns of Pbt(O(2)), NIRS, and cerebral blood flow velocity (CBFV) to changes in arterial pressure (AP) and intracranial pressure (ICP). METHODS Digital recordings of multimodal brain monitoring from 42 head-injured patients were retrospectively analysed. Response latencies and patterns of Pbt(O(2)), NIRS-derived parameters [tissue oxygenation index (TOI) and total haemoglobin index (THI)], and CBFV reactions to fluctuations of AP and ICP were studied. RESULTS One hundred and twenty-one events were identified. In reaction to alterations of AP, ICP reacted first [4.3 s; inter-quartile range (IQR) -4.9 to 22.0 s, followed by NIRS-derived parameters and CBFV (10.9 s; IQR: -5.9 to 39.6 s, 12.1 s; IQR: -3.0 to 49.1 s, 14.7 s; IQR: -8.8 to 52.3 s for THI, CBFV, and TOI, respectively), with Pbt(O(2)) reacting last (39.6 s; IQR: 16.4 to 66.0 s). The differences in reaction time between NIRS parameters and Pbt(O(2)) were significant (P<0.001). Similarly when reactions to ICP changes were analysed, NIRS parameters preceded Pbt(O(2)) (7.1 s; IQR: -8.8 to 195.0 s, 18.1 s; IQR: -20.6 to 80.7 s, 22.9 s; IQR: 11.0 to 53.0 s for THI, TOI, and Pbt(O(2)), respectively). Two main patterns of responses to AP changes were identified. With preserved cerebrovascular reactivity, TOI and Pbt(O(2)) followed the direction of AP. With impaired cerebrovascular reactivity, TOI and Pbt(O(2)) decreased while AP and ICP increased. In 77% of events, the direction of TOI changes was concordant with Pbt(O(2)). CONCLUSIONS NIRS and transcranial Doppler signals reacted first to AP and ICP changes. The reaction of Pbt(O(2)) is delayed. The results imply that the analysed modalities monitor different stages of cerebral oxygenation.
Collapse
Affiliation(s)
- K P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke' s Hospital, Hills Road, Cambridge CB2 0QQ, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Schmidt JM, Claassen J. Clinical utility of brain tissue oxygen tension in treatment of brain injury more complicated than it appears. Clin Neurophysiol 2011; 123:1060-2. [PMID: 22119796 DOI: 10.1016/j.clinph.2011.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 10/14/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022]
|
33
|
Spiotta AM, Provencio JJ, Rasmussen PA, Manno E. Brain Monitoring After Subarachnoid Hemorrhage: Lessons Learned. Neurosurgery 2011; 69:755-66; discussion 766. [DOI: 10.1227/neu.0b013e31821d2b61] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
34
|
Brain oxygen tension monitoring following penetrating ballistic-like brain injury in rats. J Neurosci Methods 2011; 203:115-21. [PMID: 21983109 DOI: 10.1016/j.jneumeth.2011.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 09/22/2011] [Accepted: 09/23/2011] [Indexed: 11/22/2022]
Abstract
While brain oxygen tension (PbtO(2)) monitoring is an important parameter for evaluating injury severity and therapeutic efficiency in severe traumatic brain injury (TBI) patients, many factors affect the monitoring. The goal of this study was to identify the effects of FiO(2) (fraction of inspired oxygen) on PbtO(2) in uninjured anesthetized rats and measure the changes in PbtO(2) following penetrating ballistic-like brain injury (PBBI). Continuous PbtO(2) monitoring in uninjured anesthetized rats showed that PbtO(2) response was positively correlated with FiO(2) (0.21-0.35) but PbtO(2) remained stable when FiO(2) was maintained at ∼0.26. Importantly, although increasing FiO(2) from 0.21 to 0.35 improved P(a)O(2), it concomitantly reduced pH levels and elevated P(a)CO(2) values out of the normal range. However, when the FiO(2) was maintained between 0.26 and 0.30, the pH and P(a)O(2) levels remained within the normal or clinically acceptable range. In PBBI rats, PbtO(2) was significantly reduced by ∼40% (16.9 ± 1.2 mm Hg) in the peri-lesional region immediately following unilateral, frontal 10% PBBI compared to sham rats (28.6 ± 1.7 mm Hg; mean ± SEM, p<0.05) and the PBBI-induced reductions in PbtO(2) were sustained for at least 150 min post-PBBI. Collectively, these results demonstrate that FiO(2) affects PbtO(2) and that PBBI produces acute and sustained hypoxia in the peri-lesional region of the brain injury. This study provides important information for the management of PbtO(2) monitoring in this brain injury model and may offer insight for therapeutic strategies targeted to improve the hypoxia/ischemia state in the penetrating-type brain injury.
Collapse
|
35
|
Bohman LE, Heuer GG, Macyszyn L, Maloney-Wilensky E, Frangos S, Le Roux PD, Kofke A, Levine JM, Stiefel MF. Medical management of compromised brain oxygen in patients with severe traumatic brain injury. Neurocrit Care 2011; 14:361-9. [PMID: 21394543 DOI: 10.1007/s12028-011-9526-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Brain tissue oxygen (PbtO(2)) monitoring is used in severe traumatic brain injury (TBI) patients. How brain reduced PbtO(2) should be treated and its response to treatment is not clearly defined. We examined which medical therapies restore normal PbtO(2) in TBI patients. METHODS Forty-nine (mean age 40 ± 19 years) patients with severe TBI (Glasgow Coma Scale [GCS] ≤ 8) admitted to a University-affiliated, Level I trauma center who had at least one episode of compromised brain oxygen (PbtO(2) <25 mmHg for >10 min), were retrospectively identified from a prospective observational cohort study. Intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO(2) were monitored continuously. Episodes of compromised PbtO(2) and brain hypoxia (PbtO(2) <15 mmHg for >10 min) and the medical interventions that improved PbtO(2) were identified. RESULTS Five hundred and sixty-four episodes of compromised PbtO2 were identified from 260 days of PbtO2 monitoring. Medical management used in a "cause-directed" manner successfully reversed 72% of the episodes of compromised PbtO(2), defined as restoration of a "normal" PbtO(2) (i.e. ≥ 25 mmHg). Ventilator manipulation, CPP augmentation, and sedation were the most frequent interventions. Increasing FiO(2) restored PbtO(2) 80% of the time. CPP augmentation and sedation were effective in 73 and 66% of episodes of compromised brain oxygen, respectively. ICP reduction using mannitol was effective in 73% of treated episodes, though was used only when PbtO(2) was compromised in the setting of elevated ICP. Successful medical treatment of brain hypoxia was associated with decreased mortality. Survivors (n = 38) had a 71% rate of response to treatment and non-survivors (n = 11) had a 44% rate of response (P = 0.01). CONCLUSION Reduced PbtO(2) may occur in TBI patients despite efforts to maintain CPP. Medical interventions other than those to treat ICP and CPP can improve PbtO(2). This may increase the number of therapies for severe TBI in the ICU.
Collapse
Affiliation(s)
- Leif-Erik Bohman
- Department of Neurosurgery, University of Pennsylvania, 3 Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Nikaina I, Paterakis K, Paraforos G, Dardiotis E, Chovas A, Papadopoulos D, Brotis A, Komnos A. Cerebral perfusion pressure, microdialysis biochemistry, and clinical outcome in patients with spontaneous intracerebral hematomas. J Crit Care 2011; 27:83-8. [PMID: 21703812 DOI: 10.1016/j.jcrc.2011.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 03/21/2011] [Accepted: 04/23/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE The aim of our study was to investigate the roles of cerebral perfusion pressure (CPP) and microdialysis marker values on the clinical outcome of patients with spontaneous intracerebral hematoma. MATERIALS AND METHODS Twenty-seven patients (18 men; mean ± SD age, 54.17 ± 10.05 years; 9 women, mean ± SD age, 65.00 ± 4.24 years) with a GCS of 8 or less upon admission were included in this study. After a 6-month follow-up period, a linear regression model was applied to evaluate the outcomes using the Glasgow Outcome Scale (GOS). RESULTS Of the 27 patients, 16 died within the first 6 months after discharge from the hospital. Six patients had a favorable prognosis after 6 months. In the patients who had a favorable outcome (GOS = 4 or GOS = 5), the CPP was above 75.46 mm Hg, and intracranial pressure was below 14.21 mm Hg. No patient with a favorable prognosis had a lactate-pyruvate (L/P) ratio greater than 37.40. An inverse linear relationship was found among the L/P ratio, the CPP, and patient outcome. CONCLUSION The L/P ratio and CPP were found to be related to patient outcome. In addition, a CPP greater than 75.46 mm Hg and an L/P ratio lower than 37.40 mm Hg were related to a favorable outcome.
Collapse
Affiliation(s)
- Irene Nikaina
- Intensive Care Unit, General Hospital of Larissa, Greece
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Orakcioglu B, Sakowitz OW, Neumann JO, Kentar MM, Unterberg A, Kiening KL. Evaluation of a Novel Brain Tissue Oxygenation Probe in an Experimental Swine Model. Neurosurgery 2010; 67:1716-22; discussion 1722-3. [DOI: 10.1227/neu.0b013e3181f9bb5b] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
38
|
|
39
|
Spiotta AM, Stiefel MF, Gracias VH, Garuffe AM, Kofke WA, Maloney-Wilensky E, Troxel AB, Levine JM, Le Roux PD. Brain tissue oxygen-directed management and outcome in patients with severe traumatic brain injury. J Neurosurg 2010; 113:571-80. [PMID: 20415526 DOI: 10.3171/2010.1.jns09506] [Citation(s) in RCA: 183] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT The object of this study was to determine whether brain tissue oxygen (PbtO(2))-based therapy or intracranial pressure (ICP)/cerebral perfusion pressure (CPP)-based therapy is associated with improved patient outcome after severe traumatic brain injury (TBI). METHODS Seventy patients with severe TBI (postresuscitation GCS score < or = 8), admitted to a neurosurgical intensive care unit at a university-based Level I trauma center and tertiary care hospital and managed with an ICP and PbtO(2) monitor (mean age 40 +/- 19 years [SD]) were compared with 53 historical controls who received only an ICP monitor (mean age 43 +/- 18 years). Therapy for both patient groups was aimed to maintain ICP < 20 mm Hg and CPP > 60 mm Hg. Patients with PbtO(2) monitors also had therapy to maintain PbtO(2) > 20 mm Hg. RESULTS Data were obtained from 12,148 hours of continuous ICP monitoring and 6,816 hours of continuous PbtO(2) monitoring. The mean daily ICP and CPP and the frequency of elevated ICP (> 20 mm Hg) or suboptimal CPP (< 60 mm Hg) episodes were similar in each group. The mortality rate was significantly lower in patients who received PbtO(2)-directed care (25.7%) than in those who received conventional ICP and CPP-based therapy (45.3%, p < 0.05). Overall, 40% of patients receiving ICP/CPP-guided management and 64.3% of those receiving PbtO(2)-guided management had a favorable short-term outcome (p = 0.01). Among patients who received PbtO(2)-directed therapy, mortality was associated with lower mean daily PbtO(2) (p < 0.05), longer durations of compromised brain oxygen (PbtO(2) < 20 mm Hg, p = 0.013) and brain hypoxia (PbtO(2) < 15 mm Hg, p = 0.001), more episodes and a longer cumulative duration of compromised PbtO(2) (p < 0.001), and less successful treatment of compromised PbtO(2) (p = 0.03). CONCLUSIONS These results suggest that PbtO(2)-based therapy, particularly when compromised PbtO(2) can be corrected, may be associated with reduced patient mortality and improved patient outcome after severe TBI.
Collapse
Affiliation(s)
- Alejandro M Spiotta
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Bordes J, Boret H, Prunet B, Montcriol A, Goutorbe P. [Carotid dissection during angioplasty for vasospasm induced by subarachnoid haemorrhage. The use of multimodal cerebral monitoring]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2009; 28:1023-1028. [PMID: 19945247 DOI: 10.1016/j.annfar.2009.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 09/30/2009] [Indexed: 05/28/2023]
Abstract
We report the case of a 54-year-old woman presenting subarachnoid haemorrhage. She experienced multiple vasospasms and treatment included triple-H (hypervolaemia, hypertension, and haemodilution) and endovascular therapies. Right internal carotid dissection complicated angioplasty of the right middle cerebral artery. Combined brain tissue partial pressure of oxygen monitoring and transcranial echo-Doppler could have facilitated early diagnosis. Despite successful revascularization of right internal carotid by stenting, this complication caused acute stroke with refractory intracranial hypertension.
Collapse
Affiliation(s)
- J Bordes
- Département d'anesthésie-réanimation, HIA Sainte-Anne, 2 boulevard Sainte-Anne, Toulon, France.
| | | | | | | | | |
Collapse
|
41
|
Liao KH, Chang CK, Chang HC, Chang KC, Chen CF, Chen TY, Chou CW, Chung WY, Chiang YH, Hong KS, Hsiao SH, Hsu YH, Huang HL, Huang SC, Hung CC, Kung SS, Kuo KN, Li KH, Lin JW, Lin TG, Lin CM, Su CF, Tsai MT, Tsai SH, Wang YC, Yang TY, Yu KF, Chiu WT. Clinical practice guidelines in severe traumatic brain injury in Taiwan. ACTA ACUST UNITED AC 2009; 72 Suppl 2:S66-73; discussion S73-4. [DOI: 10.1016/j.surneu.2009.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Accepted: 07/03/2009] [Indexed: 11/17/2022]
|
42
|
Radolovich DK, Czosnyka M, Timofeev I, Lavinio A, Kim DJ, Jaeger M, Hutchinson P, Gupta A, Pickard JD, Smielewski P. Transient changes in brain tissue oxygen in response to modifications of cerebral perfusion pressure: an observational study. Anesth Analg 2009; 110:165-73. [PMID: 19933525 DOI: 10.1213/ane.0b013e3181c0722f] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The relative merits of the mechanisms for the maintenance of brain tissue oxygenation (PbtO(2)) have been much debated. There is a wealth of studies regarding various factors that may determine the absolute value and changes in PbtO(2). However, only a few of them analyzed fast (few minutes) and transient behavior of PbtO(2) in response to variations (waves) of intracranial pressure (ICP) and cerebral perfusion pressure (CPP). METHODS This was a retrospective analysis and observational study. PbtO(2), arterial blood pressure (ABP), and ICP waveforms were digitally monitored in 23 head-injured patients, admitted to the Neuroscience Critical Care Unit, who were sedated, paralyzed, and ventilated. Computer recordings were retrospectively reviewed. The dynamic changes in PbtO(2) in response to transient changes in ABP and ICP were investigated. RESULTS Several patterns of response to short-lasting arterial hypotension and hypertension, intracranial hypertension, cerebral vasocycling, and cerebral hyperemia were observed and characterized. During the majority of the transient events, PbtO(2) generally followed the direction of changes in CPP. Only during episodes of hyperemia, CPP and PbtO(2) changed in the opposite direction. Changes in PbtO(2) were delayed after dynamic changes in ABP, CPP, and ICP. The CPP-PbtO(2) delay during changes provoked by variations in ABP was 35.0 s (range: maximum 827.0 s; minimum 0.0 s) compared with changes induced by variations in ICP of 0.0 s (range: maximum 265.0 s; minimum 0.0 s); the difference was significant at P < 0.0001. CONCLUSIONS PbtO(2) is more than a number; it is rather a waveform following rapid changes in ICP and ABP. We show that PbtO(2) generally tracks the direction of CPP irrespective of the state of cerebral autoregulation.
Collapse
Affiliation(s)
- Danila K Radolovich
- Academic Neurosurgical Unit, Department of Clinical Neuroscience, University of Cambridge, Cambridge CB2 2QQ, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Focal cerebral oxygenation and neurological outcome with or without brain tissue oxygen-guided therapy in patients with traumatic brain injury. Acta Neurochir (Wien) 2009; 151:1399-409. [PMID: 19727549 DOI: 10.1007/s00701-009-0398-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 04/26/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), the depth and duration of cerebral hypoxia are independent predictors of outcome. This study aimed to evaluate the efficacy of brain oxygen-guided therapy in improving cerebral oxygenation and neurological outcome in severe TBI patients. METHODS Thirty TBI patients had brain oxygen monitors placed contralateral to the side of mass lesions, or to the non-dominant side if injury was diffuse. The first 10 patients (Group 1, observational) had brain tissue oxygen (PbrO2) monitored, but not treated. The next 20 patients (Group 2, interventional) were treated according to brain tissue oxygen-guided algorithms aiming to improve cerebral oxygen availability. The 6-month neurological outcome of Group 2 patients was compared with that of Group 1 patients and with contemporary control patients (Group 3) treated without the use of brain oxygen monitoring. FINDINGS The mean duration of brain hypoxic episodes (PbrO2 <15 mmHg) was 106 minutes in Group 1, and 34 minutes in Group 2 (p=0.01). Brain tissue oxygen was <15 mmHg for 10% of monitoring time in Group 1 and 2.8% in Group 2 (p=0.12). The peak incidence of cerebral hypoxic events in both groups occurred during post-injury day 5. The mean Injury Severity Score (ISS) of patients experiencing cerebral hypoxia was higher than that of patients without cerebral hypoxic episodes (33.7 vs 24.2, p=0.04). There was no statistically significant difference in neurological outcome between those patients treated with and those without brain oxygen-guided therapy. CONCLUSIONS In TBI patients, brain tissue oxygen-guided therapy is associated with decreased duration of episodes of cerebral hypoxia. Larger studies are indicated to determine the effects of this therapy on neurological outcome.
Collapse
|
44
|
Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy. J Neurosurg 2009; 111:672-82. [PMID: 19463048 DOI: 10.3171/2009.4.jns081150] [Citation(s) in RCA: 215] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI). Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients. In this study, the authors describe their 5-year experience with brain tissue oxygen (PbtO(2)) monitoring, and the effect of a brain tissue oxygen-directed critical care guide (PbtO(2)-CCG) on the 6-month clinical outcome (based on the 6-month Glasgow Outcome Scale score) in patients with TBIs. METHODS One hundred thirty-nine patients admitted to Creighton University Medical Center with major traumatic injuries (Injury Severity Scale [ISS] scores >or= 16) and TBI underwent prospective evaluation. All patients were treated with a PbtO(2)-CCG to maintain a brain oxygen level > 20 mm Hg, and control ICP < 20 mm Hg. The role of demographic, clinical, and imaging parameters in the identification of patients at risk for cerebral hypooxygenation and the influence of hypooxygenation on clinical outcome were recorded. Outcomes were compared with those in a historical ICP/CPP patient cohort. Subgroup analysis of severe TBI was performed and compared to data reported in the Traumatic Coma Data Bank. RESULTS The majority of injuries were sustained in motor vehicle crashes (63%), and diffuse brain injury was the most common abnormality (58%). Mechanism of injury, severity of TBI, pathological entity, neuroimaging results, and trauma indices were not predictive of ischemia. Factors affecting death included gunshot injury, poor trauma indices, subarachnoid hemorrhage, and coma. After standard resuscitation, 65% of patients had an initially low PbtO(2). Data are presented as means +/- SDs. Treatment with the PbtO(2)-CCG resulted in a 44% improvement in mean PbtO(2) (16.21 +/- 12.30 vs 23.65 +/- 14.40 mm Hg; p < 0.001), control of ICP (mean 12.76 +/- 6.42 mm Hg), and the maintenance of CPP (mean 76.13 +/- 15.37 mm Hg). Persistently low cerebral oxygenation was seen in 37% of patients at 2 hours, 31% at 24 hours, and 18% at 48 hours of treatment. Thus elevated ICP and a persistent low PbtO(2) after 2 hours represented increasing odds of death (OR 14.3 at 48 hours). Survivors and patients with good outcomes generally had significantly higher mean daily PbtO(2) and CPP values compared to nonsurvivors. Polytrauma, associated with higher ISS scores, presented an increased risk of vegetative outcome (OR 9.0). Compared to the ICP/CPP cohort, the mean Glasgow Outcome Scale score at 6 months in patients treated with PbtO(2)-CCG was higher (3.55 +/- 1.75 vs 2.71 +/- 1.65, p < 0.01; OR for good outcome 2.09, 95% CI 1.031-4.24) as was the reduction in mortality rate (25.9 vs 41.50%; relative risk reduction 37%), despite higher ISS scores in the PbtO(2) group (31.6 +/- 13.4 vs 27.1 +/- 8.9; p < 0.05). Subgroup analysis of severe closed TBI revealed a significant relative risk reduction in mortality rate of 37-51% compared with the Traumatic Coma Data Bank data, and an increased OR for good outcome especially in patients with diffuse brain injury without mass lesions (OR 4.9, 95% CI 2.9-8.4). CONCLUSIONS The prevention and aggressive treatment of cerebral hypooxygenation and control of ICP with a PbtO(2)-directed protocol reduced the mortality rate after TBI in major trauma, but more importantly, resulted in improved 6-month clinical outcomes over the standard ICP/CPP-directed therapy at the authors' institution.
Collapse
|
45
|
Rabinstein AA. Elucidating the value of continuous brain oxygen monitoring. Neurocrit Care 2009; 12:144-5. [PMID: 19657599 DOI: 10.1007/s12028-009-9261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 07/24/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Alejandro A Rabinstein
- Division of Critical Care Neurology-Department of Neurology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
| |
Collapse
|
46
|
|
47
|
Abstract
OBJECTIVE In this study, available medical literature were reviewed to determine whether brain hypoxia as measured by brain tissue oxygen (Bto2) levels is associated with increased risk of poor outcome after traumatic brain injury (TBI). A secondary objective was to examine the safety profile of a direct BtO2 probe. DATA SOURCE AND EXTRACTION: Clinical studies published between 1993 and 2008 were identified from electronic databases, Index Medicus, bibliographies of pertinent articles, and expert consultation. The following inclusion criteria were applied for outcome analysis: 1) more than 10 patients described, 2) use of a direct Bto2 monitor, 3) brain hypoxia defined as Bto2 <10 mm Hg for >15 or 30 minutes, 4) 6-month outcome data, and 5) clear reporting of patient outcome associated with Bto2. For the analysis, each selected article had to have adequate data to determine odds ratios (ORs) and confidence intervals (CIs). Thirteen studies met the initial inclusion criteria and three were included in the final outcome analysis. Safety data were abstracted from any report where it was mentioned. DATA SYNTHESIS The three studies included 150 evaluable patients with severe TBI (Glasgow Coma Scale <or=8). Brain hypoxia was identified in 71 (47%) of these patients. Among the patients with brain hypoxia, 52 (73%) had unfavorable outcome including 39 (55%) who died. In the absence of brain hypoxia, 34 (43%) patients had an unfavorable outcome, including 17 (22%) who died. Overall brain hypoxia (Bto2 <10 mm Hg >15 minutes) was associated with worse outcome (OR 4.0; 95% CI 1.9-8.2) and increased mortality (OR 4.6; 95% CI 2.2-9.6). We reviewed published safety data; in 292 patients monitored with a Bto2 probe, only two adverse events were reported. CONCLUSION Summary results indicate that brain hypoxia (<10 mm Hg) is associated with worse outcome after severe TBI and that Bto2 probes are safe. These results imply that treating patients to increase Bto2 may improve outcome after severe TBI. This question will require further study.
Collapse
|
48
|
Komotar RJ, Schmidt JM, Starke RM, Claassen J, Wartenberg KE, Lee K, Badjatia N, Connolly ES, Mayer SA. RESUSCITATION AND CRITICAL CARE OF POOR-GRADE SUBARACHNOID HEMORRHAGE. Neurosurgery 2009; 64:397-410; discussion 410-1. [DOI: 10.1227/01.neu.0000338946.42939.c7] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abstract
AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.
Collapse
Affiliation(s)
- Ricardo J. Komotar
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
| | - J. Michael Schmidt
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | - Robert M. Starke
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
| | - Jan Claassen
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | | | - Kiwon Lee
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | - Neeraj Badjatia
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| | - E. Sander Connolly
- Neurological Intensive Care Unit, Department of Neurological Surgery, Columbia University, New York, New York
| | - Stephan A. Mayer
- Department of Neurological Surgery, Columbia University, New York, New York (Komotar)
- Neurological Intensive Care Unit, Department of Neurology, Columbia University, New York, New York
| |
Collapse
|
49
|
Chang JJJ, Youn TS, Benson D, Mattick H, Andrade N, Harper CR, Moore CB, Madden CJ, Diaz-Arrastia RR. Physiologic and functional outcome correlates of brain tissue hypoxia in traumatic brain injury. Crit Care Med 2009; 37:283-90. [PMID: 19050612 DOI: 10.1097/ccm.0b013e318192fbd7] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Assess the prevalence of brain tissue hypoxia in patients with severe traumatic brain injuries (TBI), and to characterize the relationship between brain tissue hypoxia and functional outcome. DESIGN Retrospective review of severe TBI patients. SETTING Intensive care unit of a level I trauma center. PATIENTS Twenty-seven patients with severe TBI requiring intracranial pressure (ICP) monitoring. Median age was 22 yrs, and a majority (63%) had traumatic subarachnoid hemorrhage. INTERVENTIONS Hourly assessments of ICP, brain tissue oxygen, mean arterial pressure, fraction of inspired oxygen (FiO2), partial pressure of arterial carbon dioxide (PaCO2), and hemoglobin concentration (hemoglobin) were recorded. Outcome was assessed 6-9 months postinjury. MEASUREMENTS AND MAIN RESULTS Mean (SD) ICP and BTpO2 were 13.7 (6.6) cm H2O and 30.8 (13.6) mm Hg. A total of 13.5% (379) of the BTpO2 values recorded were < 20 mm Hg, only 86 of which were associated with ICP > or = 20 cm H2O. This prevalence was comparable with episodes of ICP elevations above 20 cm H2O (14.1%, 397). Hypoxic episodes were more common when cerebral perfusion pressure was below 60 mm Hg (relative risk = 3.0, p < 0.0001). We did not find an association in hypoxic risk and hemoglobin in the range of 7-12 g/dL or PaCO2 in the range of 25-40 mm Hg. Subjects with hourly episodes (epochs) of hypoxia > 20% of the time had poorer scores on outcome measures compared with those with fewer hypoxic epochs. CONCLUSIONS Hypoxic episodes are common after severe TBI, and most are independent of ICP elevations. Most episodes of hypoxia occur while cerebral perfusion pressure and mean arterial pressure are within the accepted target range. There is no clear association between PaCO2 and hemoglobin with BTpO2. The young age and high prevalence of traumatic subarachnoid hemorrhage in this cohort may limit its generalizability. Increased frequency of hypoxic episodes is associated with poor functional outcome.
Collapse
Affiliation(s)
- Jason J J Chang
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Exo J, Smith C, Smith R, Bell MJ. Emergency treatment options for pediatric traumatic brain injury. PEDIATRIC HEALTH 2009; 3:533-541. [PMID: 20191093 PMCID: PMC2828617 DOI: 10.2217/phe.09.54] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Traumatic brain injury is a leading killer of children and is a major public health problem around the world. Using general principles of neurocritical care, various treatment strategies have been developed to attempt to restore homeostasis to the brain and allow brain healing, including mechanical factors, cerebrospinal fluid diversion, hyperventilation, hyperosmolar therapies, barbiturates and hypothermia. Careful application of these therapies, normally in a step-wise fashion as intracranial injuries evolve, is necessary in order to attain maximal neurological outcome for these children. It is hopeful that new therapies, such as early hypothermia or others currently in preclinical trials, will ultimately improve outcome and quality of life for children after traumatic brain injury.
Collapse
Affiliation(s)
- J Exo
- Department of Critical Care Medicine, & The Safar Center for Resuscitation, Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - C Smith
- Department of Critical Care Medicine, & The Safar Center for Resuscitation, Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - R Smith
- Department of Critical Care Medicine, & The Safar Center for Resuscitation, Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - MJ Bell
- Department of Critical Care Medicine, & The Safar Center for Resuscitation, Research, University of Pittsburgh, Pittsburgh, PA, USA, Tel.: +1 412 692 5164, Fax: +1 412 692 6076,
| |
Collapse
|