Pressure Reactivity-Based Optimal Cerebral Perfusion Pressure in a Traumatic Brain Injury Cohort (original) (raw)
Related papers
Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury*
Critical Care Medicine, 2012
S urvival after traumatic brain injury (TBI) is dependent on the control of intracranial hypertension and the provision of hemodynamic support to achieve an "adequate" cerebral perfusion pressure (CPP). However, the idea of a single value (or even a single range) of CPP being adequate for the diverse group of TBI patients is an oversimplification (1-3). Age and premorbid arterial blood pressure (ABP) are examples of factors likely to influence individual CPP targets, with elderly, hypertensive patients requiring a higher CPP compared with young, normotensive patients. Although multimodal brain monitoring, including continuous brain-tissue oxygenation, near infrared spectroscopy, transcranial Doppler ultrasonography, and microdialysis provide valuable information at the bedside regarding the adequacy of CPP, these technologies are costly and restricted to a relatively small number of specialized neurocritical care units. The 2007 Brain Trauma Foundation guidelines advocated randomized controlled trials to verify the feasibility and the impact on outcome of strategies based on individualized CPP management following severe TBI (4). A method for individualization of CPPoriented management based on determination of cerebrovascular reactivity Objectives: We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPP opt ) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPP opt algorithm by determining the association between outcome and the deviation of actual CPP from CPP opt .
Critical Care, 2020
Background After traumatic brain injury (TBI), brain tissue can be further damaged when cerebral autoregulation is impaired. Managing cerebral perfusion pressure (CPP) according to computed “optimal CPP” values based on cerebrovascular reactivity indices might contribute to preventing such secondary injuries. In this study, we examined the discriminative value of a low-resolution long pressure reactivity index (LPRx) and its derived “optimal CPP” in comparison to the well-established high-resolution pressure reactivity index (PRx). Methods Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset, the association of LPRx (correlation between 1-min averages of intracranial pressure and arterial blood pressure over a moving time frame of 20 min) and PRx (correlation between 10-s averages of intracranial pressure and arterial blood pressure over a moving time frame of 5 min) to outcome was assessed and compared using univar...
Critical Care
Background A previous retrospective single-centre study suggested that the percentage of time spent with cerebral perfusion pressure (CPP) below the individual lower limit of reactivity (LLR) is associated with mortality in traumatic brain injury (TBI) patients. We aim to validate this in a large multicentre cohort. Methods Recordings from 171 TBI patients from the high-resolution cohort of the CENTER-TBI study were processed with ICM+ software. We derived LLR as a time trend of CPP at a level for which the pressure reactivity index (PRx) indicates impaired cerebrovascular reactivity with low CPP. The relationship with mortality was assessed with Mann-U test (first 7-day period), Kruskal–Wallis (daily analysis for 7 days), univariate and multivariate logistic regression models. AUCs (CI 95%) were calculated and compared using DeLong’s test. Results Average LLR over the first 7 days was above 60 mmHg in 48% of patients. %time with CPP < LLR could predict mortality (AUC 0.73, p = ...
Journal of Neurosurgery, 2015
OBJECT The pressure reactivity index (PRx) correlates with outcome after traumatic brain injury (TBI) and is used to calculate optimal cerebral perfusion pressure (CPPopt). The PRx is a correlation coefficient between slow, spontaneous changes (0.003–0.05 Hz) in intracranial pressure (ICP) and arterial blood pressure (ABP). A novel index—the so-called long PRx (L-PRx)—that considers ABP and ICP changes (0.0008–0.008 Hz) was proposed. METHODS The authors compared PRx and L-PRx for 6-month outcome prediction and CPPopt calculation in 307 patients with TBI. The PRx- and L-PRx–based CPPopt were determined and the predictive power and discriminant abilities were compared. RESULTS The PRx and L-PRx correlation was good (R = 0.7, p < 0.00001; Spearman test). The PRx, age, CPP, and Glasgow Coma Scale score but not L-PRx were significant fatal outcome predictors (death and persistent vegetative state). There was a significant difference between the areas under the receiver operating chara...
Journal of Critical Care, 2017
Purpose: The maintenance of patient-specific optimal cerebral perfusion pressure (CPPopt) is crucial for patients with traumatic brain injury (TBI). The goal of the prospective study was to explore the influence of CPP declination from CPPopt value on the TBI patients' outcome. Methods: The CPP and cerebrovascular autoregulation (CA) monitoring of 52 TBI patients was performed. Patient-specific CPPopt has been identified and the associations between the patients' outcome and complex influence of time of CPP declination from CPPopt value, age, and the duration of CA impairment episodes has been analyzed. Results: The multiple correlation coefficient between the Glasgow Outcome Scale (GOS), duration of CA impairment events and percentage time, when 0<ΔCPPopt<10 mmHg was r=-0.643 (P<0.001). The multiple correlation coefficients between GOS, age, and percentage time of ΔCPPopt when 0<ΔCPPopt <10 mmHg was r=-0.587 (P<0.001). Conclusion: The CPPopt-targeted patient-specific management might be useful for stabilizing CA in TBI patients as well as for improving their outcome. Better outcomes were obtained by maintaining CPP in light hyperperfusion condition (up to 10 mmHg above CPPopt) when CPPopt is in the range of 60-80 mmHg, and keeping CPP within the range of CPPopt +/-5 mmHg when CPPopt is above 80 mmHg.
Critical Care Medicine, 2002
C erebrovasCular pressure reactivity reflects the capability of smooth muscle tone in the walls of cerebral arteries and arterioles to react to changes in transmural pressure (cerebral vessels constrict in response to an increase in CPP, and vice versa). Cerebro-vascular pressure reactivity represents a key element of cerebral autoregulation, although the two terms should not be used interchangeably because vascular responses can occur outside the range of cerebral autoregulation. 7,25 With increasing ABP, intact cerebrovascular pressure reactivity will lead to vasoconstriction and a reduction of cerebral blood volume. Under the condition of a finite pressure-volume compensatory reserve, this reduction of cerebral blood volume will produce a decrease in ICP, a condition that is usually not met in patients after a decompressive craniectomy or in those with an external ventricular drain. When cerebrovascular pressure reac
Journal of neurotrauma, 2017
Methods to identify an autoregulation guided 'optimal' cerebral perfusion pressure (CPPopt) for traumatic brain injury patients (TBI) have been reported through several studies. An important drawback of existing methodology is that CPPopt can be calculated only in approximately 50-60% of the monitoring time. In this study, we hypothesized that the CPPopt yield and the continuity can be improved significantly through application of a multi-window and weighting calculation algorithm, without adversely affecting preservation of its prognostic value. Data of 526 severe TBI patients admitted between 2003 and 2015 were studied. The multi-window CPPopt calculation was based on automated curve fitting in pressure reactivity index (PRx)-CPP plots using data from 36 increasing length time windows (2 to 8 hours). The resulting matrix of CPPopts was then averaged in a weighted manner. The yield, continuity, and stability of CPPopt were studied. The difference between patients' actua...
Cerebral perfusion pressure insults and associations with outcome in adult traumatic brain injury
Journal of neurotrauma, 2017
The definition of cerebral perfusion pressure (CPP) secondary insults in severe traumatic brain injury remains unclear. The purpose of the present study is to visualize the association of intensity and duration of episodes below or above cerebral perfusion pressure thresholds and outcome. The analysis was based on prospectively collected minute-by-minute intracranial pressure (ICP) and blood pressure data and outcome from 259 adult patients. The relationship of episodes of CPP below or above a certain threshold for certain duration with the 6-month Glasgow Outcome Score was visualized, separately for episodes of active or deficient autoregulation (AR). In adults ≤ 65y, an almost exponential transition curve separates the episodes of CPP associated with better outcomes from the episodes of low CPP associated with worse outcomes, indicating that lower CPP could only be tolerated for a brief time. Analysis of episodes of high CPP again showed a time-intensity dependent association with...
BMJ Open
IntroductionIndividualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines.Methods and analysisCPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intrac...