Time spent with impaired autoregulation is linked with outcome in severe infant/paediatric traumatic brain injury

Hockel, Konstantin; Diedler, Jennifer; Neunhoeffer, Felix; Heimberg, Ellen; Nagel, Carmen; Schuhmann, Martin U.

doi:10.1007/s00701-017-3308-8

Cited by 23 publications

(21 citation statements)

References 27 publications

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“…We read a recent paper from Prof. Martin Schuhmann's group [13] with great interest. It describes thresholds of PRx in pediatric post-TBI brain monitoring and analyzes their association with outcome.…”

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confidence: 99%

Pressure reactivity index: journey through the past 20 years

Czosnyka

Smielewski

2017

Acta Neurochir

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Autoregulation after traumatic brain injury can be monitored continuously using simple signal processing of intracranial pressure and arterial blood pressure. The pressure reactivity index (PRx) showed several benefits when it was applied to continuous brain monitoring. Among them, a positive and strong correlation with the outcome and possibility of calculation of 'optimal cerebral perfusion pressure' have been listed. For this methodology, prospective clinical trials are missing-few of them are planned in the near future.Keywords Traumatic brain injury . Intracranial pressure . Arterial blood pressure . Optimal cerebral perfusion pressureThe pressure-reactivity index was first described in 1995. Originally, we were inspired by the presentation of Erhard Lang and Randal Chestnut during the ICRAN conference at Gold Coast, Australia (1994). They reported that they could read a state of cerebral autoregulation from relative changes in mean arterial blood pressure (ABP) and intracranial pressure (ICP). They told us that it was enough to ask a research nurse to sit in front of a bedside monitor and instruct her to observe trends of ABP and ICP. The nurse needed to report when the values were changing in the same or opposite directions. When we arrived home, we programmed our computers, running ICM (intensive care monitor) software [7], to calculate a moving correlation coefficient from 30 consecutive 10-s averages of ICP and ABP waveforms. We called this the PRx index (pressure reactivity index) [6].The rationale for averaging ICP and ABP waveforms over 10 s was that only slow waves, of frequencies lower than 0.05 Hz, can carry information about autoregulation [11]. Simple averaging is a sufficient method of filtration of all faster components (mainly respiratory and pulsatile), which do not contain or contain only a little of any autoregulationrelated signatures.The rationale for calculating the correlation coefficient from 5-min-long buffers (30 samples of 10 s produce correlation window of 5 min) is that longer periods (e.g., 30 or 60 min) may include too many reactions to drugs, nursingrelated variations, metabolic reactions, etc. They are all not related to cerebral autoregulation and would produce distortion of the PRx.When a few years later a postgraduate student from S w i t ze r l an d , L uz i u s S t e i n er ( no w P r o f e s s o r o f Anaesthesiology at University of Basel), came to our Laboratory of Brain Physics in Cambridge, asking whether he could be given a PhD project on PRx, we first took it for a joke. However, over the next 3 years we were proven very wrong. Works of Luzius and other clinical neuroscientists who followed in his footsteps brought to light perhaps the most important advantage of PRx, its ability to guide the management of cerebral perfusion pressure. The concept was so simple to understand and so appealing in the clinical setting that many more people than we initially anticipated embraced it enthusiastically and developed it further.After 20 years, summarizing the mile...

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confidence: 99%

Pressure reactivity index: journey through the past 20 years

Czosnyka

Smielewski

2017

Acta Neurochir

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“…30 In contrast, CPP opt is significantly correlated with patient's age 31 and when optimized, it is associated with better outcomes. [31][32][33][34] Indeed, the data suggest that multimodal monitoring should be used to understand the cerebral pathophysiology of individual patients after severe pediatric TBI.…”

Section: Discussionmentioning

confidence: 99%

Severe Traumatic Brain Injury in French-Speaking Pediatric Intensive Care Units: Study of Practices

Denis

Lauzier

Roumeliotis

et al. 2022

J Pediatr Intensive Care

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Best strategies for managing severe pediatric traumatic brain injury (TBI) are not established, with wide variations among professional practices. The main objective of this study was to assess compliance with updated pediatric TBI management guidelines (2019). A survey was distributed among French-speaking pediatric intensive care physicians from April 1 to June 30, 2019. The survey was based on a clinical case with a total of 70 questions that cover the 15 items of the 2019 TBI guidelines. The questions evaluated the assessment and management of TBI during the acute and intensive care phases. Of 487 e-mails sent, 78 surveys were included. Guidelines were adhered to (> 60%) for 10 of 15 items in the guidelines. Strong adherence to recent guideline changes was achieved for seizure prophylaxis with levetiracetam (n = 21/33, 64%) and partial pressure of carbon dioxide threshold (n = 52, 67%). However, management of the sodium and glucose thresholds and the role of transcranial Doppler were not consistent with the guidelines. Assessment of brain tissue oxygenation (n = 12, 16%) and autoregulation (n = 35, 45%) was not a common practice. There was strong agreement among clinicians on the intracranial pressure (> 80%) and cerebral perfusion pressure (> 70%) thresholds used according to age. Overall, stated practices for the management of TBI appear to be relatively standardized among responders. Variations persist in areas with a lack of evidence and pediatric-specific recommendations.

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“…36 Impairments in autoregulation are associated with worse neurological outcome, particularly when unilateral or prolonged. 29,50,51,70 Knowledge of autoregulation status facilitates tailored management of the TBI patient, as patients with intact autoregulation may see improvements in ICP control and brain tissue oxygenation with augmented CPP.…”

Section: Cerebral Autoregulation In Traumamentioning

confidence: 99%

Transcranial Doppler ultrasonography in neurological surgery and neurocritical care

Bonow

Young

Bass

et al. 2019

Neurosurgical Focus

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Transcranial Doppler (TCD) ultrasonography is an inexpensive, noninvasive means of measuring blood flow within the arteries of the brain. In this review, the authors outline the technology underlying TCD ultrasonography and describe its uses in patients with neurosurgical diseases. One of the most common uses of TCD ultrasonography is monitoring for vasospasm following subarachnoid hemorrhage. In this setting, elevated blood flow velocities serve as a proxy for vasospasm and can herald the onset of ischemia. TCD ultrasonography is also useful in the evaluation and management of occlusive cerebrovascular disease. Monitoring for microembolic signals enables stratification of stroke risk due to carotid stenosis and can also be used to clarify stroke etiology. TCD ultrasonography can identify patients with exhausted cerebrovascular reserve, and after extracranial-intracranial bypass procedures it can be used to assess adequacy of flow through the graft. Finally, assessment of cerebral autoregulation can be performed using TCD ultrasonography, providing data important to the management of patients with severe traumatic brain injury. As the clinical applications of TCD ultrasonography have expanded over time, so has their importance in the management of neurosurgical patients. Familiarity with this diagnostic tool is crucial for the modern neurological surgeon.

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Time spent with impaired autoregulation is linked with outcome in severe infant/paediatric traumatic brain injury

Cited by 23 publications

References 27 publications

Pressure reactivity index: journey through the past 20 years

Pressure reactivity index: journey through the past 20 years

Severe Traumatic Brain Injury in French-Speaking Pediatric Intensive Care Units: Study of Practices

Transcranial Doppler ultrasonography in neurological surgery and neurocritical care

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