Continuous Vital Sign Analysis to Predict Secondary Neurological Decline After Traumatic Brain Injury

Abstract

Background: In the acute resuscitation period after traumatic brain injury (TBI), one of the goals is to identify those at risk for secondary neurological decline (ND), represented by a constellation of clinical signs that can be identified as objective events related to secondary brain injury and independently impact outcome. We investigated whether continuous vital sign variability and waveform analysis of the electrocardiogram (ECG) or photoplethysmogram (PPG) within the first hour of resuscitation may enhance the ability to predict ND in the initial 48 hours after traumatic brain injury (TBI).Methods: Retrospective analysis of ND in TBI patients enrolled in the prospective Oximetry and Noninvasive Predictors Of Intervention Need after Trauma (ONPOINT) study. ND was defined as any of the following occurring in the first 48 h: new asymmetric pupillary dilatation (>2 mm), 2 point GCS decline, interval worsening of CT scan as assessed by the Marshall score, or intervention for cerebral edema. Beat-to-beat variation of ECG or PPG, as well as waveform features during the first 15 and 60 min after arrival in the TRU were analyzed to determine physiologic parameters associated with future ND. Physiologic and admission clinical variables were combined in multivariable logistic regression models predicting ND and inpatient mortality.Results: There were 33 (17%) patients with ND among 191 patients (mean age 43 years old, GCS 13, ISS 12, 69% men) who met study criteria. ND was associated with ICU admission (P < 0.001) and inpatient mortality (P < 0.001). Both ECG (AUROC: 0.84, 95% CI: 0.76,0.93) and PPG (AUROC: 0.87, 95% CI: 0.80, 0.93) analyses during the first 15 min of resuscitation demonstrated a greater ability to predict ND then clinical characteristics alone (AUROC: 0.69, 95% CI: 0.59, 0.8). Age (P = 0.02), Marshall score (P = 0.001), penetrating injury (P = 0.02), and predictive probability for ND by PPG analysis at 15 min (P = 0.03) were independently associated with inpatient mortality.Conclusions: Analysis of variability and ECG or PPG waveform in the first minutes of resuscitation may represent a non-invasive early marker of future ND.

Neurocritical Care: Bench to Bedside (Eds. Claude Hemphill, Michael James) Integrating and Using Big Data in Neurocritical Care

“…T h e c o n c e p t o f "neuroworsening" is critical to define when considering using Big Data to predict important changes in the neurocritical care unit. However, neuroworsening is poorly defined in clinical practice despite its definition within federally funded TBI common data elements [60] and requires careful adjudication for use even in post hoc data analysis [61]. Nursing observations that describe a neuroworsening event might exist as free text in the EHR only, if, at all, completely separated from the data that could be used to predict such an event.…”

Pulse rate variability in cardiovascular health: a review on its applications and relationship with heart rate variability

“…Syncope(Kamiya et al 2005). Traumatic brain injury(Melinosky et al 2018). Identification of increased risk of hospital admission(Garde et al 2016b).…”

The Modified Early Warning Score: A Useful Marker of Neurological Worsening but Unreliable Predictor of Sepsis in the Neurocritically Ill—A Retrospective Cohort Study

“…Our findings further pose the question whether a score such as MEWS-SRS/MEWS might be, possibly with additional modifications, able to more precisely and earlier predict neurologic worsening in the neuro-ICU population. Current developments in neuro-ICU bioinformatics with prediction analysis of vital signs would support this conceptual framework ( 20 ) but are often based on waveform analysis, limiting availability, and practicality. Our results demonstrated neurologic worsening as the most common clinical change associated with a MEWS-SRS score greater than or equal to 5.…”