Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury

We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPPopt algorithm by determining th...

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Published inCritical care medicine Vol. 40; no. 8; p. 2456
Main Authors Aries, Marcel J H, Czosnyka, Marek, Budohoski, Karol P, Steiner, Luzius A, Lavinio, Andrea, Kolias, Angelos G, Hutchinson, Peter J, Brady, Ken M, Menon, David K, Pickard, John D, Smielewski, Peter
Format Journal Article
LanguageEnglish
Published United States 01.08.2012
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Abstract We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPPopt algorithm by determining the association between outcome and the deviation of actual CPP from CPPopt. Retrospective analysis of prospectively collected data. Neurosciences critical care unit of a university hospital. A total of 327 traumatic head-injury patients admitted between 2003 and 2009 with continuous monitoring of arterial blood pressure and intracranial pressure. Arterial blood pressure, intracranial pressure, and CPP were continuously recorded, and pressure reactivity index was calculated online. Outcome was assessed at 6 months. An automated curve fitting method was applied to determine CPP at the minimum value for pressure reactivity index (CPPopt). A time trend of CPPopt was created using a moving 4-hr window, updated every minute. Identification of CPPopt was, on average, feasible during 55% of the whole recording period. Patient outcome correlated with the continuously updated difference between median CPP and CPPopt (chi-square=45, p<.001; outcome dichotomized into fatal and nonfatal). Mortality was associated with relative "hypoperfusion" (CPP<CPPopt), severe disability with "hyperperfusion" (CPP>CPPopt), and favorable outcome was associated with smaller deviations of CPP from the individualized CPPopt. While deviations from global target CPP values of 60 mm Hg and 70 mm Hg were also related to outcome, these relationships were less robust. Real-time CPPopt could be identified during the recording time of majority of the patients. Patients with a median CPP close to CPPopt were more likely to have a favorable outcome than those in whom median CPP was widely different from CPPopt. Deviations from individualized CPPopt were more predictive of outcome than deviations from a common target CPP. CPP management to optimize cerebrovascular pressure reactivity should be the subject of future clinical trial in severe traumatic head-injury patients.
AbstractList We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPPopt algorithm by determining the association between outcome and the deviation of actual CPP from CPPopt. Retrospective analysis of prospectively collected data. Neurosciences critical care unit of a university hospital. A total of 327 traumatic head-injury patients admitted between 2003 and 2009 with continuous monitoring of arterial blood pressure and intracranial pressure. Arterial blood pressure, intracranial pressure, and CPP were continuously recorded, and pressure reactivity index was calculated online. Outcome was assessed at 6 months. An automated curve fitting method was applied to determine CPP at the minimum value for pressure reactivity index (CPPopt). A time trend of CPPopt was created using a moving 4-hr window, updated every minute. Identification of CPPopt was, on average, feasible during 55% of the whole recording period. Patient outcome correlated with the continuously updated difference between median CPP and CPPopt (chi-square=45, p<.001; outcome dichotomized into fatal and nonfatal). Mortality was associated with relative "hypoperfusion" (CPP<CPPopt), severe disability with "hyperperfusion" (CPP>CPPopt), and favorable outcome was associated with smaller deviations of CPP from the individualized CPPopt. While deviations from global target CPP values of 60 mm Hg and 70 mm Hg were also related to outcome, these relationships were less robust. Real-time CPPopt could be identified during the recording time of majority of the patients. Patients with a median CPP close to CPPopt were more likely to have a favorable outcome than those in whom median CPP was widely different from CPPopt. Deviations from individualized CPPopt were more predictive of outcome than deviations from a common target CPP. CPP management to optimize cerebrovascular pressure reactivity should be the subject of future clinical trial in severe traumatic head-injury patients.
Author Lavinio, Andrea
Aries, Marcel J H
Brady, Ken M
Kolias, Angelos G
Hutchinson, Peter J
Menon, David K
Steiner, Luzius A
Smielewski, Peter
Czosnyka, Marek
Budohoski, Karol P
Pickard, John D
Author_xml – sequence: 1
  givenname: Marcel J H
  surname: Aries
  fullname: Aries, Marcel J H
  email: m.j.h.aries@umcg.nl
  organization: Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, and Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK. m.j.h.aries@umcg.nl
– sequence: 2
  givenname: Marek
  surname: Czosnyka
  fullname: Czosnyka, Marek
– sequence: 3
  givenname: Karol P
  surname: Budohoski
  fullname: Budohoski, Karol P
– sequence: 4
  givenname: Luzius A
  surname: Steiner
  fullname: Steiner, Luzius A
– sequence: 5
  givenname: Andrea
  surname: Lavinio
  fullname: Lavinio, Andrea
– sequence: 6
  givenname: Angelos G
  surname: Kolias
  fullname: Kolias, Angelos G
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  surname: Hutchinson
  fullname: Hutchinson, Peter J
– sequence: 8
  givenname: Ken M
  surname: Brady
  fullname: Brady, Ken M
– sequence: 9
  givenname: David K
  surname: Menon
  fullname: Menon, David K
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  givenname: John D
  surname: Pickard
  fullname: Pickard, John D
– sequence: 11
  givenname: Peter
  surname: Smielewski
  fullname: Smielewski, Peter
BackLink https://www.ncbi.nlm.nih.gov/pubmed/22622398$$D View this record in MEDLINE/PubMed
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References 23269170 - Crit Care Med. 2013 Jan;41(1):e4-5
22809937 - Crit Care Med. 2012 Aug;40(8):2526-7
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Snippet We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe...
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StartPage 2456
SubjectTerms Adolescent
Adult
Aged
Aged, 80 and over
Blood Pressure - physiology
Brain Injuries - physiopathology
Cerebrovascular Circulation - physiology
Female
Humans
Intracranial Pressure - physiology
Male
Middle Aged
Monitoring, Physiologic
Retrospective Studies
Time Factors
Treatment Outcome
Young Adult
Title Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury
URI https://www.ncbi.nlm.nih.gov/pubmed/22622398
Volume 40
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