Guidelines for Cerebral Perfusion Pressure

doi:10.1089/neu.2000.17.507

Cited by 110 publications

(9 citation statements)

References 41 publications

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“…29 Intracranial pressure alone is a more familiar zero point reference for calculating cerebral perfusion pressure. 30 This is valid when small differences in vascular wall tension are not significant relative to ABP. During transition and the early newborn period, ABP in premature infants is low enough that small variances of either vascular wall tension or intracranial pressure can substantively impact the effective cerebral perfusion pressure.…”

Section: Discussionmentioning

confidence: 99%

Elevated Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants

Rhee

Kaiser

Rios

et al. 2016

The Journal of Pediatrics

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Objective To determine if the diastolic closing margin (DCM), defined as diastolic blood pressure minus critical closing pressure, is associated with the development of early severe intraventricular hemorrhage (IVH). Study design A reanalysis of prospectively collected data was conducted. Premature infants receiving mechanical ventilation (n = 185) with gestational age 23–31 weeks had ~1 hour continuous recordings of umbilical arterial blood pressure, middle cerebral artery cerebral blood flow velocity, and arterial carbon dioxide tension during the first week of life. Models using multivariate generalized linear regression and purposeful selection were used to determine associations with severe IVH. Results Severe IVH (grades 3–4) was observed in 14.6% of infants. Apgar score at 5-minutes and DCM were significantly associated with severe IVH, irrespective of the model. A clinically relevant 5-mm Hg increase in DCM was associated with a 1.83–1.89 increased odds of developing severe IVH. Conclusion Elevated DCM was associated with severe IVH, consistent with previous animal data showing IVH is associated with hyperperfusion. Measurement of DCM may be more useful than blood pressure in defining cerebral perfusion in premature infants.

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Section: Discussionmentioning

confidence: 99%

Elevated Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants

Rhee

Kaiser

Rios

et al. 2016

The Journal of Pediatrics

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“…ICP and CPP management were based on the Brain Trauma Foundation Guidelines and were performed continuously per each ICU's protocol (16,17). ICP management was protocolized by the study only for the hour after dosing when the EVD was closed.…”

Section: Methodsmentioning

confidence: 99%

“…Low CPP events were defined at thresholds, CPP < 60 or CPP < 70 mm Hg. CPP < 60 mm Hg and ICP > 20 mm Hg were considered threshold levels for treatment, based on Brain Trauma Foundation Guidelines (16,17). …”

Section: Methodsmentioning

confidence: 99%

Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage*

Ziai

Melnychuk

Thompson

et al. 2012

Critical Care Medicine

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Objective Elevated intracranial pressure (ICP) is one of the proposed mechanisms leading to poor outcomes in patients with intraventricular hemorrhage (IVH). We sought to characterize the occurrence and significance of intracranial hypertension in severe IVH requiring extraventricular drainage (EVD). Design Prospective analysis from two randomized multicenter clinical trials. Setting Intensive care units of 23 academic hospitals. Patients One hundred patients with obstructive IVH, and intracerebral hemorrhage (ICH) volume < 30cc requiring emergency EVD from two randomized multicenter studies comparing intraventricular recombinant tissue plasminogen activator (rt-PA) (n=78) to placebo (n=22). Interventions ICP was recorded every 4 hours in all patients and before and after a 1 hr EVD closure period post-injection. ICP readings were analyzed at pre-defined thresholds and compared between treatment groups, pre- and post-injection of study agent, and pre- and post-opening of 3rd and 4th ventricles on CT. Impact on 30 day outcomes was assessed. Measurements and Main Results Initial ICP ranged from −2 to 60 mm Hg (median, interquartile range; 11,10). Of 2576 ICP readings, 91.5% (2359) were ≤ 20 mm Hg, 1.6% were >30, 0.5% were >40, and 0.2% were > 50 mm Hg. In a multivariate analysis threshold events > 20 and > 30 mm Hg were more frequent in placebo vs. rt-PA treated groups (p=0.03 and p=0.08, respectively). ICP elevation > 20 mm Hg occurred during a required 1 hr EVD closure interval in 207/868 (23.8%) injections of study agent although early re-opening of the EVD only occurred in 7.9%. After radiographic opening of the lower ventricular system, ICP events > 20 mmHg remained significantly associated with initial IVH volume (p=0.002), and EVD placement ipsilateral to the largest IVH volume (p=0.001), but not with thrombolytic treatment (p=0.05) or ICH volume (p=0.14). VP shunts were required in 13.6% of Pcb and 6.4% of rt-PA treated patients (p=0.37). Percentage of ICP readings per patient > 30 mmHg, and initial ICH and IVH volumes were independent predictors of 30 day mortality after adjustment for other outcome predictors (p=0.003; p=0.03; p<0.001, respectively). Independent predictors of poor modified Rankin Score (mRS) at 30 days were % of ICP events > 30 mmHg/patient (p=0.01) (but not > 20 mmHg), both ICH and IVH volume and pulse pressure. Conclusions ICP is not frequently elevated during monitoring and drainage with an EVD in patients with severe IVH although ICP > 30 mm Hg predicts higher short-term mortality. Thrombolytic therapy may reduce the frequency of high ICP events. ICP elevation appears to be significantly correlated with EVD placement in the ventricle with greatest clot volume.

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“…Low CPP events were defined at two thresholds, CPP <60 or <70 mm Hg. CPP <60 mm Hg and ICP >20 mm Hg were considered threshold levels for treatment based on Brain Trauma Foundation guidelines [13, 14]. …”

Section: Methodsmentioning

confidence: 99%

Frequency of Sustained Intracranial Pressure Elevation during Treatment of Severe Intraventricular Hemorrhage

et al. 2009

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Background: Elevated intracranial pressure (ICP) is an important marker of neurological deterioration. The occurrence and significance of elevated ICP and low cerebral perfusion pressure (CPP) in aggressively treated spontaneous intraventricular hemorrhage (IVH) are not defined. Methods: We performed a secondary longitudinal exploratory data analysis of a randomized multicenter trial of urokinase (UK) versus placebo (Pcb) as a treatment for IVH. Eleven IVH patients who required an external ventricular drain (EVD) were randomized to receive either intraventricular UK or Pcb every 12 h until clinical response permitted EVD removal. ICP and CPP were recorded every 4 or 6 h, as well as before and 1 h after EVD closure for administration of study agent. ICP, CPP and the proportion of ICP readings above 20, 30, 40 and 50 mm Hg were analyzed. Results: Six UK and 5 Pcb patients aged 39–74 years (mean ± standard deviation; 53 ± 11 years) were enrolled. Initial ICP ranged from 0 to 38 mm Hg (10.9 ± 11.0), initial CPP from 65 to 133 mm Hg (100.5 ± 17.7). We recorded 472 ICP readings over the entire monitoring period. Of these 65 (14%) were >20 mm Hg, 23 (5%) >30 mm Hg, 9 (2%) >40 mm Hg and 3 (<1%) >50 mm Hg. Only 2 of 141 intraventricular injections of study agent with EVD closure were not tolerated and required reopening of the EVD. Conclusions: In the intensive care unit, initial ICP measured with an EVD was uncommonly elevated (1/11 patients) in this group of severe IVH patients despite acute obstructive hydrocephalus. Frequent monitoring reveals ICP elevation >20 mm Hg in 14% of observations during use of EVD. ICP elevation, though it can occur, is not routinely associated with EVD closure for thrombolytic treatment with UK.

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Guidelines for Cerebral Perfusion Pressure

Cited by 110 publications

References 41 publications

Elevated Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants

Elevated Diastolic Closing Margin Is Associated with Intraventricular Hemorrhage in Premature Infants

Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage*

Frequency of Sustained Intracranial Pressure Elevation during Treatment of Severe Intraventricular Hemorrhage

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