A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients

Lin, Chien Min; Lin, Ming‐Chin; Huang, Sheng Jean; Chang, Cheng; Chao, Dan Ping; Lui, Tai Ngar; Hsin, I.; Liu, Ming Ying; Chung, Wen‐Hsin; Shih, Yang Hsin; Tsai, Shin Han; Chiou, Hung Yi; Lin, Mau Roung; Jen, Sen Li; Li, Wei; Wu, Chung-Che; Lin, En Yuan; Liao, Kuo Hsing; Chiang, Yung Hsiao; Chiu, Wen Ta; Lin, Jia Wei

doi:10.1155/2015/529580

Cited by 43 publications

(53 citation statements)

References 38 publications

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“…3 Several works published more recently have also explored the effect of P bt O 2 values on outcome after head injury. 10,17,19 Maloney-Wilensky published a systematic review in 2009 of 3 studies including 150 patients recovering from severe TBI. 19 It was concluded that brain hypoxia (P bt O 2 < 10 mm Hg) is associated with worse outcome after TBI and that treating patients to increase P bt O 2 may improve neurological outcome.…”

Section: The Literature Basis For Existing P Bt O 2 Treatment Thresholdsmentioning

confidence: 99%

“…28 In 2015 Lin et al published a prospective randomized study to compare the effect of P bt O 2 -guided therapy with traditional intracranial pressure-guided treatment on outcome in moderate and severe TBI patients. 17 They employed a P bt O 2 threshold of 20 mm Hg and concluded that the survival rate in the P bt O 2 -guided group was significantly increased at 3 and 6 months after injury, indicating that therapy directed by P bt O 2 monitoring is valuable for treatment in these patients. Eriksson et al published a study in 2012 and concluded that the first 72 hours of P bt O 2 monitoring predicts mortality similar to the analysis we present in this study.…”

Section: The Literature Basis For Existing P Bt O 2 Treatment Thresholdsmentioning

confidence: 99%

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Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Hirschi

Hawryluk

Nielson

et al. 2019

Journal of Neurosurgery

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OBJECTIVEBrain tissue hypoxia is common after traumatic brain injury (TBI). Technology now exists that can detect brain hypoxia and guide corrective therapy. Current guidelines for the management of severe TBI recommend maintaining partial pressure of brain tissue oxygen (PbtO2) > 15–20 mm Hg; however, uncertainty persists as to the optimal treatment threshold. The object of this study was to better inform the relationship between PbtO2 values and outcome for patients with TBI.METHODSPbtO2 measurements were prospectively and automatically collected every minute from consecutive patients admitted to the San Francisco General Hospital neurological ICU during a 6-year period. Mean PbtO2 values in TBI patients as well as the proportion of PbtO2 values below each of 75 thresholds between 0 mm Hg and 75 mm Hg over various epochs up to 30 days from the time of admission were analyzed. Patient outcomes were determined using the Glasgow Outcome Scale. The authors explored putative treatment thresholds by generating 675 separate receiver operating characteristic curves and 675 generalized linear models to examine each 1–mm Hg threshold for various epochs.RESULTSA total of 1,380,841 PbtO2 values were recorded in 190 TBI patients. A high proportion of PbtO2 measures were below 20 mm Hg irrespective of the examined epoch. Time below treatment thresholds was more strongly associated with outcome than mean PbtO2. A treatment window was suggested: a threshold of 19 mm Hg most robustly distinguished patients by outcome, especially from days 3–5; however, benefit was suggested from maintaining values at least as high as 33 mm Hg.CONCLUSIONSThis analysis of high-frequency physiological data substantially informs the relationship between PbtO2 values and outcome. The results suggest a therapeutic window for PbtO2 in TBI patients along with minimum and preferred PbtO2 treatment thresholds, which may be examined in future studies. Traditional treatment thresholds that have the strongest association with outcome may not be optimal.

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Section: The Literature Basis For Existing P Bt O 2 Treatment Thresholdsmentioning

confidence: 99%

Section: The Literature Basis For Existing P Bt O 2 Treatment Thresholdsmentioning

confidence: 99%

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Hirschi

Hawryluk

Nielson

et al. 2019

Journal of Neurosurgery

View full text Add to dashboard Cite

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“…52 PbtO 2 has most robust evidence among all cerebral oxygenation-monitoring techniques, and multiple studies have demonstrated an association between low PbtO 2 and poor outcomes after TBI independent of ICP and CPP. 41,42,53,54 There is recent suggestion to routinely place probe in normal appearing brain, typically in the nondominant frontal lobe. 55 As with ICP therapy, a stepwise management approach is also used for PbtO 2 augmentation, which includes optimization of MAP/CPP, respiratory manipulations, and blood transfusions (in the setting of anemia).…”

Section: Brain Tissue Oxygen Partial Pressurementioning

confidence: 99%

Multimodal Neuromonitoring: Current Scenario in Neurocritical Care

Goyal

Khandelwal

Kedia

2019

Journal of Neuroanaesthesiology and Critical Care

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Multimodal neuromonitoring (NM) is the concept of integrating various tools and data to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. There exists a range of invasive/noninvasive and global/regional monitors of cerebral hemodynamics, oxygenation, metabolism, and electrophysiology that can be used to guide treatment decisions after neurological insult. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows individualized patient care. The ability to analyze these advanced data for real-time clinical care, however, remains intuitive and primitive. Advanced informatics is promising and may provide us a supportive tool to interpret physiological events and guide pathophysiological-based therapeutic decisions. Available literature is not robust regarding multimodality NM and favorable patient outcome. This narrative review is undertaken to know the status and recent advancement of multimodal NM in neurocritical care.

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“…At 3 months, the PbtO 2 goal directed therapy group had significantly more favorable outcome rates (64.3% compared to 39.6%) [ 87 ]. Other groups have similarly showed a decrease in mortality and improved 6-month GOS outcomes with the addition of goal directed PbtO 2 therapy over standard ICP/CPP therapy alone [ 88 , 89 ]. In aSAH, PbtO 2 monitoring has less of a role in predicting vasospasm or outcome [ 90 ].…”

Section: Pbto 2 Monitoringmentioning

confidence: 99%

Brain Monitoring in Critically Neurologically Impaired Patients

Jones

Schwartzbauer

Jia

2016

IJMS

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Assessment of neurologic injury and the evolution of severe neurologic injury is limited in comatose or critically ill patients that lack a reliable neurologic examination. For common yet severe pathologies such as the comatose state after cardiac arrest, aneurysmal subarachnoid hemorrhage (aSAH), and severe traumatic brain injury (TBI), critical medical decisions are made on the basis of the neurologic injury. Decisions regarding active intensive care management, need for neurosurgical intervention, and withdrawal of care, depend on a reliable, high-quality assessment of the true state of neurologic injury, and have traditionally relied on limited assessments such as intracranial pressure monitoring and electroencephalogram. However, even within TBI there exists a spectrum of disease that is likely not captured by such limited monitoring and thus a more directed effort towards obtaining a more robust biophysical signature of the individual patient must be undertaken. In this review, multimodal monitoring including the most promising serum markers of neuronal injury, cerebral microdialysis, brain tissue oxygenation, and pressure reactivity index to access brain microenvironment will be discussed with their utility among specific pathologies that may help determine a more complete picture of the neurologic injury state for active intensive care management and long-term outcomes. Goal-directed therapy guided by a multi-modality approach appears to be superior to standard intracranial pressure (ICP) guided therapy and should be explored further across multiple pathologies. Future directions including the application of optogenetics to evaluate brain injury and recovery and even as an adjunct monitoring modality will also be discussed.

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A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients

Cited by 43 publications

References 38 publications

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold

Multimodal Neuromonitoring: Current Scenario in Neurocritical Care

Brain Monitoring in Critically Neurologically Impaired Patients

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