Clinical and Physiological Events That Contribute to the Success Rate of Finding “Optimal” Cerebral Perfusion Pressure in Severe Brain Trauma Patients

Weersink, Corien S. A.; Aries, Marcel; Dias, Celeste; Liu, Mary X.; Kolias, Angelos G.; Donnelly, Joseph E.; Czosnyka, Marek; Dijk, J. Marc C. van; Regtien, Joost G.; Menon, David; Hutchinson, Peter J.; Smielewski, Peter

doi:10.1097/ccm.0000000000001165

Cited by 37 publications

(23 citation statements)

References 23 publications

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“…The cerebral hypoperfusion index was significantly associated with outcome. Indeed for both ICP and CPP a personalized threshold may ultimately need to be derived based not only on ICP and CPP values, but additional information such as brain tissue oxygenation, microdialysis monitoring, or pressure reactivity index, as was suggested recently in the work of Weersink et al and Allen et al (19, 20). …”

Section: Discussionmentioning

confidence: 99%

Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults

Ferguson

Shein

Kochanek

et al. 2016

Pediatric Critical Care Medicine

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Objective The evidence to guide therapy in pediatric TBI is lacking, including insight into the ICP/CPP thresholds in abusive head trauma (AHT). We examined ICP/CPP thresholds and indices of ICP and CPP burden in relationship to outcome in severe TBI and in accidental and AHT cohorts. Design A prospective observational study. Setting PICU in a tertiary children’s hospital. Patients Children <18y admitted to PICU with severe TBI and had ICP monitoring. Measurements and Main Results A pediatric TBI database was interrogated with 85 patients (18 AHT) enrolled. Hourly ICP and CPP (in mm Hg) were collated and compared to various thresholds. C-statistics for ICP and CPP data in the entire population were determined. Intracranial hypertension and cerebral hypoperfusion indices were formulated based on number of hours with ICP>20 and CPP<50, respectively. A secondary analysis was performed on accidental and AHT cohorts. All of these were compared with dichotomized 6 month GOS scores. The models with the number of hours with ICP>20 (C=0.641, 95% confidence interval: 0.523, 0.762) and CPP<45 (C=0.702, 95% confidence interval: 0.586, 0.805) had the best fits to discriminate outcome. Two factors were independently associated with a poor outcome, number of hours ICP>20 and AHT (OR=5.101, 95% CI: 1.571, 16.563). As the number of hours with ICP>20 increase by 1, the odds of a poor outcome increased by 4.6% (OR=1.046, 95% CI: 1.012, 1.082). Thresholds did not differ between accidental vs. AHT. The intracranial hypertension and cerebral hypoperfusion indices were both associated with outcome. Conclusion The duration of hours of ICP>20 and CPP<45 best discriminated poor outcome. As the number of hours ICP>20 increase by 1, the odds of a poor outcome increased by 4.6%. Although AHT was strongly associated with unfavorable outcome, ICP/CPP thresholds did not differ between accidental and AHT.

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Section: Discussionmentioning

confidence: 99%

Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults

Ferguson

Shein

Kochanek

et al. 2016

Pediatric Critical Care Medicine

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“…CPPopt is the level of cerebral perfusion pressure (CPP = MAP - ICP) within a given range where PRx is the lowest, i.e., where the status of autoregulation is optimal for the patient [26]. In TBI, patients with CPP close to their calculated optimum had better outcomes than those with large deviations, and treatment protocols focused on CPPopt have been proposed [1, 11, 29, 31]. Assessment of CPPopt is feasible also in patients with intracerebral hemorrhage and SAH, but the literature is limited, and there is a need for further studies to clarify the utility of CPPopt especially in SAH patients [3, 12, 22].…”

Section: Introductionmentioning

confidence: 99%

Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP

et al. 2017

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BackgroundCerebral pressure autoregulation can be quantified with the pressure reactivity index (PRx), based on the correlation between blood pressure and intracranial pressure. Using PRx optimal cerebral perfusion pressure (CPPopt) can be calculated, i.e., the level of CPP where autoregulation functions best. The relation between cerebral blood flow (CBF) and CPPopt has not been examined. The objective was to assess to which extent CPPopt can be calculated in SAH patients and to investigate CPPopt in relation to CBF.MethodsRetrospective study of prospectively collected data. CBF was measured bedside with Xenon-enhanced CT (Xe-CT). The difference between actual CPP and CPPopt was calculated (CPP∆). Correlations between CPP∆ and CBF parameters were calculated with Spearman’s rank order correlation coefficient (rho). Separate calculations were done using all patients (day 0–14 after onset) as well as in two subgroups (day 0–3 and day 4–14).ResultsEighty-two patients with 145 Xe-CT scans were studied. Automated calculation of CPPopt was possible in adjunct to 60% of the Xe-CT scans. Actual CPP < CPPopt was associated with higher numbers of low-flow regions (CBF <10 ml/100 g/min) in both the early phase (day 0–3, n = 39, Spearman’s rho = −0.38, p = 0.02) and late acute phase of the disease (day 4–14, n = 35, Spearman’s rho = −0.39, p = 0.02). CPP level per se was not associated with CBF.ConclusionsCalculation of CPPopt is possible in a majority of patients with severe SAH. Actual CPP below CPPopt is associated with low CBF.

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“…These findings raise questions as to the role of the autonomic nervous system, 52,54,99 inflammatory mediators, 59,100,101 and TBI therapeutic interventions (e.g. deep sedation, fluids, cooling, transfusion) 7,10,11,102 in the acute phase, in driving impaired autoregulation in TBI. Further investigation of all of the above patient and injury factors is ongoing as part of the CENTER-TBI High Resolution ICU Sub-Study objectives.…”

Section: Association With Patient and Injury Factorsmentioning

confidence: 99%

“…Despite the strong links between impaired cerebrovascular reactivity and patient outcome, current BTF based therapies pay limited attention to continuous updated vascular reactivity status. 7,10,11 A large 25 yr retrospective single-centre study, analysing 1146 critically ill TBI patients with invasive ICP monitoring, provides some evidence to support the lack of BTF-based treatment effect on continuously measures cerebrovascular reactivity. 7 Within this analysis, ICP, CPP and PRx were assessed in each patient across the archived ICU physiology recording period.…”

Section: Current Status Of Treatment For Dysfunctional Cerebrovasculamentioning

confidence: 99%

Continuous cerebrovascular reactivity monitoring in moderate/severe traumatic brain injury: a narrative review of advances in neurocritical care

Zeiler

Ercole

Czosnyka

et al. 2020

British Journal of Anaesthesia

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Impaired cerebrovascular reactivity in adult moderate and severe traumatic brain injury (TBI) is known to be associated with worse global outcome at 6e12 months. As technology has improved over the past decades, monitoring of cerebrovascular reactivity has shifted from intermittent measures, to experimentally validated continuously updating indices at the bedside. Such advances have led to the exploration of individualised physiologic targets in adult TBI management, such as optimal cerebral perfusion pressure (CPP) values, or CPP limits in which vascular reactivity is relatively intact. These targets have been shown to have a stronger association with outcome compared with existing consensus-based guideline thresholds in severe TBI care. This has sparked ongoing prospective trials of such personalised medicine approaches in adult TBI. In this narrative review paper, we focus on the concept of cerebral autoregulation, proposed mechanisms of control and methods of continuous monitoring used in TBI. We highlight multimodal cranial monitoring approaches for continuous cerebrovascular reactivity assessment, physiologic and neuroimaging correlates, and associations with outcome. Finally, we explore the recent 'state-of-the-art' advances in personalised physiologic targets based on continuous cerebrovascular reactivity monitoring, their benefits, and implications for future avenues of research in TBI.

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Clinical and Physiological Events That Contribute to the Success Rate of Finding “Optimal” Cerebral Perfusion Pressure in Severe Brain Trauma Patients

Abstract: This study identified six factors that were independently associated with absence of optimal cerebral perfusion pressure curves.

Cited by 37 publications

References 23 publications

Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults

Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults

Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP

Continuous cerebrovascular reactivity monitoring in moderate/severe traumatic brain injury: a narrative review of advances in neurocritical care

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