11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome?

Transcription

1 11. Traumatic brain injury. Links between ICP, CPP, PRx monitoring and outcome after TBI. Does CT picture help in prediction of outcome? Critical levels of CPP, ICP and PRx

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3 Percentage of patients in outcome category 70 * 60 PreNCCU NCCU 50 * Favourable outcome Severe disability /PVS Dead * :p < 0.05 Thanks to Prof.D.Menon

4 Historical factors

5 frequency Distributions of GCS and GOS GCS Note that the data are NOT representative of ALL NCCU admissions From: 10 years of ICP monitoringseminar in 2002

6 GOSm Trouble with GCS: Before 1997 GCS was strongly Correlated with GOS p=0.22; post GCS After we can no longer see such a correlation in our material

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8 Distribution of outcomes versus ICP and CPP

9 Mortality rates versus ICP

10 Mortality rate dramatically depends on PRX

11 ROC curves for mortality/survival Thanks to Dr.M.Aries

12 Pediatric ICU patients The average PRx values from the entire monitoring period for 16 cases Brady K et al. Continuous Monitoring of Cerebrovascular Reactivity AfterTraumatic Brain Injury in Children. Critical Care Medicine. [in review] (finally published in Pediatrics Dec;124(6):e )

13 PRx opt Outcome and PRx opt during first 48 hours after SAH Bijlenga P, Czosnyka M, Budohoski KP, Soehle M, Pickard JD, Kirkpatrick PJ, Smielewski P "Optimal cerebral perfusion pressure" in poor grade patients after subarachnoid hemorrhage. Neurocrit Care Aug;13(1): p = Survived PRx 0 > Died 4 5 % death Mean SEM Survived Dead N = 16 N = P = 0.06

14 Rationale for optimal CPP: Outcome seems to be associated with mean CPP (529 head injuries, Addenbrooke s Hospital)

15 cpp-cppopt cpp-cppopt Optimal CPP; Global results: CPP<CPPopt Means and 95.0 Percent LSD Intervals P= Survived gos>3 Died CPP>CPPopt+5 Means and 95.0 mm Percent Hg LSD p=0.045 Intervals Thanks to Dr.M.Aries Favourable Unfavourable gos>2

16 abs(cpp-cppopt) Global results Means and 95.0 Percent LSD Intervals 5.9 P= Favourable 0 Unfavourable 1 gos>2 Thanks to Dr.M.Aries

17 CPPoptimal as individual threshold value gos>3 gos>3 Individual threshold Means and 95.0 Percent LSD Intervals P=1.37*E-12; F= cpp>cppopt-2 Means and 95.0 Percent LSD Intervals 0.8 P=1.71E-8; F=35 Global threshold cpp>69 Thanks to Dr.M.Aries

18 Result -GENDER The rate of mortality was significantly higher in female then in male (38% females, 26% males; p<0.046). The percentage of favorable outcome was lower in female group, but this difference didn t reach statistical relevance (43% female, 52% male; p=0.14). No significant difference was found in the severe disability group (22% males, 19% females). 60% 50% 40% 30% 20% Female Male 10% 0% Favourable outcome Severe disability Dead Thanks to Dr.M.Balestreri

19 PRx CPP ICP Higher ICP, lower CPP and worse pressure reactivity were observed in females. Age distribution and the severity of the brain trauma were comparable in the two different groups. FEMALE MALE FEMALE MALE FEMALE MALE No significant difference was found between mean values of ABP (male: mmhg; female: mmhg). Thanks to Dr.M.Aries

20 GOS:AGE R=0.28, p< Age

21 Parameters versus age

22 Pressure-reactivity gets worse with age!

23 Is there any specific timetrend in monitored parameters? Red- died Blue-survived Days Thanks to Dr. M.Balestreri

24 Hypothermia- does it improve outcome? Yes- stroke, Non-conclusive results-tbi

25 Introduction of CPP- therapy 1997 The reported changes were followed by a decrease in increase in the percentage of patients with severe disability that reached statistical significance (from 17% to 28%; p<0.01). Mortality showed a tendency (although insignificant) to decrease from 30% to 23% (p=0.11). The percentage of patients with favourable outcome did not change (50%-48%). 60% 50% 40% 30% 20% 10% * % Favourable outcome Severe disability Dead Thanks to Dr. M.Balestreri

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27 Thanks to Dr.M.Hiler

28 Thresholds for monitored variables: Methodology Series of 2x2 tables with calculation of Pearson s chi square for sequential thresholds for different parameters with respect to survival and favourable outcome Multiple logistic regression to test the validity of the parameters as independent predictors Thanks to Dr.Enrico Sorrentino

29 Thanks to Dr.Enrico Sorrentino Results for ICP

30 Thanks to Dr.Enrico Sorrentino Results for PRx

31 Thanks to Dr.Enrico Sorrentino Results for CPP

32 Highlight thresholds of ICP for favourable outcome Thanks to Dr.Enrico Sorrentino

33 OUTCOME SURVIVAL Thanks to Dr.Enrico Sorrentino Multiple logistic regression Nagelkerke R square B S.E. Wald df Sig. Exp(B) Age < Gender GCS < CPP ICP < PRx Nagelkerke R square B S.E. Wald df Sig. Exp(B) Age < Gender GCS < CPP ICP PRx

34 Conclusions - 1 Multiple logistic regression confirms the independent prognostic value of age, GCS, ICP and PRx (but not of gender and CPP). CPP threshold at 70 mmhg both for survival and favourable outcome ICP threshold at 22 mmhg both for survival and favourable outcome Thanks to Dr.Enrico Sorrentino

35 Conclusions - 2 The thresholds we found are remarkably consistent, except: PRx has two different thresholds, 0.05 and 0.25, for favourable outcome and survival respectively Women and patients >55 years of age have a lower ICP threshold for outcome at 18 mmhg Thanks to Dr.Enrico Sorrentino

36 Is good outcome always good? Orbitofrontal Damage: Case of Phineas Gage Figures: Skull of Phineas Gage 1860 and tamping iron Thanks to Prof JD Pickard

37 DIFFICULT BIT: PATIENT FOLLOW-UP Clinical Outcome is measured using Glasgow Outcome Scale. SF-36 - Quality of Life questionnaire. Do the assessments give us a full picture of patient and family requirements once they have gone home? Thanks to Prof JD Pickard

38 Amazing relationship between MMSE and mean CPP in patients with favourable outcome

39 Options for ICP control: -metabolic suppression, -EVD, -manitol, -5% NaCl, -hyperventilation (?), -hypothermia (?), -Lund protocol (?), -surgical decompression

40 Message to take home Outcome after severe head injury is multifactorial Predictors: Age, GCS, Marshall Score in initial CT, sex (?) Monitoring: mean ICP, CPP (?), autoregulation indices, PbtiO2 (?), microdialysis (?) Important factor to improve outcome: treatment in specialized centre Hypothermia? Decompression?