The management of cerebral perfusion pressure and intracranial pressure after severe head injury (original) (raw)
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Acta Neurochirurgica, 1994
A group of 74 patients with head injury (54 severe, 17 moderate and 3 minor) had continuous monitoring of both arterial and intracranial pressure with computer-based registration of these pressures, cerebral perfusion pressure and other vairables. In 60 patients cerebral perfusion pressure CPP fell below 60 mm Hg for periods of 5 minutes or longer. The distribution over time of these reductions in CPP during up to 12 days of monitoring was studied, and each episode of reduced CPP was attributed to a fall in arterial pressure, an increase in intracranial pressure, or both. Two clusters of reduced CPP were found, one during the first 24 hours of monitoring, when reduced CPP was mainly caused by a reduction in arterial pressure, and the other at 5 or 6 days after injury, when reduced CPP was due mainly to an increase in intracranial pressure.
Neurocritical Care, 2006
To investigate the relationships between intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome after traumatic brain injury. A retrospective analysis of prospectively recorded data from 429 patients after head injury requiring intensive treatment on the Neuroscience Intensive Annex and the Neuro Critical Care Unit, Cambridge, UK. ICP, CPP, and arterial blood pressure (ABP) were continuously recorded. Mean values of pressures were compared to outcome assessed at 6 months after injury (using the Glasgow Outcome Scale). The mortality rate was greater in those having mean ICP greater than 20 mmHg (17% below versus 47% above; p < 0.0001). The mortality rate was dramatically increased for CPP below 55 mmHg (81% below versus 23% above; p < 0.0001). For values of CPP greater than 95 mmHg, favorable outcome was less frequent (50% below versus 28% above; p < 0.033). The rate of severe disability showed the tendency to increase with CPP ( r = 0.87; p = 0.02), suggesting that a higher CPP does not help in achieving favorable outcomes. ICP was greater in those who died in comparison to those who survived (27 +/- 19 mmHg versus 16 +/- 6 mmHg; p < 0.10 - 7), and CPP was lower (68 +/- 21 versus 76 +/- 10 mmHg; p < 0.0002). There was no difference between mean ICP and CPP in good/moderate and severe disability outcome groups. High ICP is strongly associated with fatal outcome. Excessive CPP seems to reduce the probability of achieving a favorable outcome following head trauma.
Intracranial hypertension in head injury: management and results
Intensive Care Medicine, 1999
High intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) are serious threats after head injury . ICP monitoring and control are, therefore, crucial in the care of severe head-injured patients. Despite this, ICP control is still not widely used in American and European centers . Indications for ICP monitoring are still being debated and complications feared. Many aspects of ICP therapy, such as hyperventilation or vasopressors, are controversial [6±9]. We report on a series of patients managed with combined surgical and medical interventions aimed at controlling ICP and CPP. We set out to describe the patterns of ICP and CPP, to quantify the complications of ICP monitoring, and to summarize a management protocol and its results.
Asian Journal of Surgery, 2009
with a total of 30 patients included in the study. In our study, univariate analysis showed a statistically significant relationship between mean intracranial pressure (ICP) as well as cerebral perfusion pressure (CPP) with both states of basal cistern and the degree of diffuse injury and oedema based on the Marshall classification system. The ICP was higher while CPP and compliance were lower whenever the basal cisterns were effaced in cases of cerebral oedema with Marshall III and IV. In comparison, the study revealed lower ICP, higher mean CPP and better mean cerebral compliance if the basal cisterns were opened or the post operative CT brain scan showed Marshall I and II. These findings suggested the surgical evacuation of clots to reduce the mass volume and restoration of brain anatomy may reduce vascular engorgement and cerebral oedema, therefore preventing intracranial hypertension, and improving cerebral perfusion pressure and cerebral compliance. Nevertheless the study did not find any significant relationship between midline shifts and mean ICP, CPP or cerebral compliance even though lower ICP, higher CPP and compliance were frequently observed when the midline shift was less than 0.5 cm. As the majority of our patients had multiple and diffuse brain injuries, the absence of midline shift did not necessarily mean lower ICP as the pathology was bilateral and even when after excluding the multiple lesions, the result remained insignificant. We assumed that the CT brain scan obtained after evacuation of the mass lesion to assess the state basal cistern and classify the diffuse oedema may prognosticate the intracranial pressure and cerebral perfusion pressure thus assisting in the acute post operative management of severely head injured patients. Hence post operative CT brain scans may be done to verify the ICP and CPP readings postoperatively. Subsequently, withdrawal of sedation for neurological assessment after surgery could be done if the CT brain scan showed an opened basal cistern and Marshall I and II coupled with ICP of less than 20 mmHg. [Asian J Surg 2009;32(3):157-62]
Critical care management of severe head injury
Anaesthesia & Intensive Care Medicine, 2014
Severe traumatic brain injury (TBI) is a significant cause of morbidity and mortality. The intensive care management of TBI requires a coordinated and comprehensive approach to treatment, including strategies to prevent secondary brain injury by avoidance of systemic physiological disturbances, such as hypotension, hypoxaemia, hypoglycaemia, hyperglycaemia and hyperthermia, and maintenance of adequate cerebral perfusion and oxygenation. There have been marked improvements in the management of patients with severe TBI over the last two decades, and treatment advances in the pre-hospital setting and emergency department have recently extended into the intensive care unit. The management of head injury has undergone extensive revision as evidence accumulates that established practices are not as effective or innocuous as previously believed. Management protocols have evolved with international consensus, providing guidelines that assist clinicians in delivering optimal care. Improved diagnostic and monitoring modalities are improving the understanding of the pathophysiology of head injury and allowing the delivery of individualised therapy.