Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

Stiefel, Michael F.; Spiotta, Alejandro M; Gracias, Vincent H.; Garuffe, Alicia; Guillamondegui, Oscar M.; Maloney-Wilensky, Eileen; Bloom, Stephanie; Grady, M. Sean; LeRoux, Peter D.

doi:10.3171/jns.2005.103.5.0805

Cited by 392 publications

(202 citation statements)

References 47 publications

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“…Dings et al, in 1998, reported that patients with lower cerebral oxygenation showed lower Glasgow Outcome Scores (GOS) at 6 months [22]. Stiefel et al, showed significant improvement in patient outcomes when they added oxygen monitoring to their TBI treatment protocol [23]. In our study of 56 patients, 19 patients (34%) had episodes of cerebral desaturation in spite of normal ICP.…”

Section: Discussionmentioning

confidence: 70%

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI

Palmer¹,

Bader²

2008

TOCCMJ

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Abstract:Introduction: Standard monitoring of severe traumatic brain injury patients (TBI) by intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring fails to recognize episodes of cerebral oxygen desaturation. We found and characterized frequent episodes of desaturation of jugular venous oxygen (SjO2) in the face of normal ICP and CPP.Methods: Fifty six patients with severe TBI had SjO2 and ICP monitors placed. The charts were retrospectively reviewed and all episodes of desaturation were recorded and characterized.Results: Nineteen patients had episodes of desaturation with normal ICP and CPP. The average GCS score was 5.8. 63% of desaturations occurred in the first 24 hours, 17% of desaturations occurred in 24-48 hours, and 20% occurred in 48-72 hours. The depth of desaturation was 50-54% in 50% of instances, 45-49% in 37% of instances, and 40-44% in 13% of instances. The duration of the desaturation episodes was less than 10 minutes in 47%, 10-30 minutes in 17%, 30-60 minutes in 23%, and greater than 50 minutes in 13%. Treatment of the desaturation was elevation of FIO2 in all patients, elevation of pCO2 in 15 patients, volume expansion in 9 patients, pressors in 9 patients, and Propofol in 5 patients. Conclusions:The monitoring of severe TBI patients with ICP and CPP alone is insufficient to recognize cerebral oxygen desaturation episodes in 34% of patients. The monitoring of SjO2 facilitates the recognition and treatment of these episodes.

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Section: Discussionmentioning

confidence: 70%

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI

Palmer¹,

Bader²

2008

TOCCMJ

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“…Brain oxygenation can be measured by jugular venous oxygen saturation (SjO 2 ) [48] or by brain tissue oxygen tension (PbO 2 ) [49]. Lower SjO 2 values (<50%) or PbO 2 values less than 15 mmHg have been associated with worse outcomes [50].…”

Section: Biomarkers For Acute Managementmentioning

confidence: 99%

Biomarkers in Neurocritical Care

Kimberly

2012

Neurotherapeutics

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The gold standard for assessing neurological function is the bedside clinical examination. However, in neurocritical patients, the signs and symptoms related to the severity of illness can often be ambiguous. It can be hard to distinguish between a severe but stable disease state and one that is dynamic and in a critical decline. Clinicians and family members alike may struggle with the uncertainty of functional outcome prediction. Intermediate biomarkers of brain injury can assist with ongoing clinical management of patients, and in some circumstances can guide prognosis. Used in the right setting, biomarkers in neurocritical care can also aid with decisions to intensify treatment or avoid prolonged and unnecessary therapy. The term biomarker is used in various ways, and here we use it to refer to 3 general types: 1) circulating blood macromolecules, 2) brain imaging, and 3) continuous invasive monitors. Despite its promise, biomarkers have several limitations and should be interpreted in the context of the overall clinical assessment.

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“…Evidence suggests that the noninjured brain can tolerate tissue oxygen levels significantly lower than normal values for short periods before injury results, as long as perfusion is maintained (54)(55)(56). In contrast, brain tissue hypoxia (, 20 mm Hg) is associated with poor outcomes in the severely injured brain and oxygendirected strategies may improve outcomes (27,56,57). Although the optimal strategy to restore brain tissue oxygen tension to normal levels after brain injury is unknown, guidelines recommend targeting oxygenation values toward or within normal limits (58,59).…”

Section: Perspectivesmentioning

confidence: 99%

“…In the normal state of health, the average Pa O2 at sea level is approximately 100 mm Hg in adults less than 55 years of age (25), and the average brain tissue O 2 level is 25-35 mm Hg (26,27). In ARDS (28), a common goal is to maintain Pa O2 above 60 mm Hg, based on the classical teaching to defend against the risk of a fall in arterial oxygenation while on the steep portion of the oxygen-hemoglobin dissociation curve (29) so as to avoid oxygenation in the refractory hypoxemia range (Figure 1).…”

Section: The Case Of Arterial Oxygenation Target In Ardsmentioning

confidence: 99%

Can We Optimize Long-Term Outcomes in Acute Respiratory Distress Syndrome by Targeting Normoxemia?

et al. 2014

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Since its original description in 1967, acute respiratory distress syndrome (ARDS) has been recognized as a devastating condition associated with significant morbidity and mortality. Advances in critical care medicine and ARDS management have led to a substantial increase in the number of ARDS survivors. Longterm cognitive impairment after critical illness is a significant public health concern. ARDS survivors frequently experience long-term cognitive impairment, as well as physical impairment, psychiatric morbidity, and reduced health-related quality of life. At present, no intensive care unit-based intervention has been proven to reduce the risk of long-term cognitive impairment after ARDS. To address the urgent need to identify strategies to preserve long-term health, investigators have advocated the measurement of short-and long-term outcomes in clinical trials. Maintaining adequate oxygen delivery to preserve organ function is of vital importance in ARDS management. The optimal target range for arterial oxygenation in ARDS remains unknown, due in part to the challenge to maintain adequate tissue oxygenation and to minimize harm, such as oxygen toxicity. An approach targeted to subnormal oxygenation values (partial pressure of arterial oxygen, 55-80 mm Hg) has emerged as a means to accomplish these aims. In this perspective, we critically evaluate this strategy from short-and long-term perspectives, with a focus on the potential long-term cognitive effects of the strategy. We conclude with a proposal to consider resetting the target range for arterial oxygenation higher (85-110 mm Hg) as a potential strategy to improve the long-term outcomes of ARDS survivors.

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Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring

Abstract: The use of both ICP and brain tissue PO2 monitors and therapy directed at brain tissue PO2 is associated with reduced patient death following severe TBI.

Cited by 392 publications

References 47 publications

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI

Biomarkers in Neurocritical Care

Can We Optimize Long-Term Outcomes in Acute Respiratory Distress Syndrome by Targeting Normoxemia?

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