Brain under pressure Managing ICP. Giuseppe

Transcription

1 Brain under pressure Managing ICP Giuseppe

2 Intro Thresholds Treating HICP Conclusions NO COI for this presentation

3 Produces pressure gradients: herniation HIGH ICP Reduces CBF Negative impact on outcome

4 Level I and II A The new insufficient evidence There was insufficient evidence to support a Level I or II A recommendation for this topic. Level II B Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2016

5 Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care. Intensive Care Med Aug 20. Recommendation ICP and CPP monitoring are recommended as a part of protocol-driven care in patients who are at risk of elevated intracranial pressure based on clinical and/or imaging features. (Strong recommendation, moderate quality of evidence.)

6 GCS 8 and CT abnormalities Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233

7 American Heart Association/American Stroke Association ICP monitoring should be undertaken in patients with more severe SAH (WFNS 3), and that a ventricular catheter should be used as the ICP monitoring device because it offers the possibility of therapeutic draining of CSF to treat hydrocephalus Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 43(6),

8 International prospective observational StudY on intracranial PreSsurE in intensive care (ICU) The SYNAPSE-ICU Study ClinicalTrials.gov Identifier: NCT

9 Primary Injury Age Pre-injury health, Genetic factors Biological Response Progressive damage Secondary Insults Secondary Damage High ICP, low CPP, seizures, fever Final Outcome

10 Primary Injury Age Pre-injury health, Genetic factors Progressive damage Counteracting secondary Insults ICU monitoring Biological Response Reduce secondary damage Final Outcome

11 Intro Thresholds Treating HICP Conclusions

12 Historical thresholds (with Rx) <20

13 Probability Probability Why are we using 20mmHg? Good outcome Veg/Death % ICP>20 mmhg % ICP>20 mmhg Marmarou A, Anderson R, Ward J, Choi S, Young H, Eisenberg H, Foulkes M, Marshall L, Jane J. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. Special Supplements 1991; 75: 59 66

14 Lost in clinical translation Marmarou TCDB Simplistic interpretation Beyond age, admission motor score and pupils, the proportion of lcp measurements >20 mmhg is most indicative of outcome 20 mmhg is the threshold for starting therapy BTF till the 3 rd Treatment should be initiated with ICP thresholds above 20mmHg (Level II)

15 Sorrentino E, Diedler J, Kasprowicz M, Budohoski KP, Haubrich C, Smielewski P, Outtrim JG, Manktelow A, Hutchinson PJ, Pickard JD, Menon DK, Czosnyka M. Critical Thresholds for Cerebrovascular Reactivity After Traumatic Brain Injury. Neurocrit Care 2011;

16 Level II B 22 is the new 20 Treating ICP above 22 mm Hg is recommended because values above this level are associated with increased mortality. Carney, N., Totten, A. M., OʼReilly, C., Ullman, J. S., Hawryluk, G. W. J., Bell, M. J., et al. (2016). Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery,

17 Are these two patients really different? A B 40 ICP 40 ICP Therapy No therapy

18 A B 40 ICP 40 ICP mabp 70 mabp Which is the sickest patients?

19 15-19 micp micp Badri, S., Chen, J., Barber, J., Temkin, N. R., Dikmen, S. S., Chesnut, R. M., Deem, S., et al. (2012). Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Medicine, 38(11), doi: /s

20 ICP Dose Vik A et al. (2008) Relationship of dose of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 109:

21 Kaplan Meier survival curve of patients with asah stratified according to levels of PTDICP20 Magni F, Pozzi M, Rota M, Vargiolu A, Citerio G. High-Resolution Intracranial Pressure Burden and Outcome in Subarachnoid Hemorrhage. Stroke 2015; 46:

22 Güiza, F., Depreitere, B., Piper, I., Citerio, G., Chambers, I., Jones, P. A., et al. (2015). Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Medicine, ICP time burden Intensity*Time Adults Ped

23 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233

24 Intro Thresholds Treating HICP Conclusions

25 1965 Continuous recording of the ventricular-fluid pressure in eases of severe traumatic injury of the head facilitates the evaluation of intracranial dynamics and offers a more rational basis for treatment than do conventional control measures. Lundberg N, Troupp H, Lorin H. Continuous recording of the ventricular-fluid pressure in patients with severe acute traumatic brain injury. A preliminary report. J Neurosurg 1965; 22:

26 Level I and II A The new insufficient evidence There was insufficient evidence to support a Level I or II A recommendation for this topic. Level II B Management of severe TBI patients using information from ICP monitoring is recommended to reduce in-hospital and 2-week post-injury mortality. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2016

27 Odds ratios of neurological outcomes at 1 year, comparing intracranial pressure (ICP) patterns SD/V versus GR/MD D versus GR/MD D versus all other outcomes Normal ICP Raised but reducible ICP Refractory ICP Glasgow Outcome Score: GR, Good Recovery; MD, Moderate Disability; SD, Severe Disability; V, Vegetative; D, Death Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Treggiari. Neurocrit Care (2007) 6:

28 Stocchetti, Carbonara, Citerio Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:

29 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:

30 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:

31 Sedation Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233

32 ICP target If ICP >20-25 mmhg If ICP controlled > 24 hrs Continue sedation Add therapy for HICP Re-evaluate the case/icp therapy intensive level Evaluate ceeg for titrating the dose Test withdrawal if successful: stop sedation if unsuccessful: restart sedation

33 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:

34 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233

35 Hyperosmolar fluids for the management of elevated ICP in neurocritical care patients Are available hyperosmolar fluids effective in reducing ICP? Hyperosmolar fluids (MAN, HTS, HTL) are effective in reducing ICP. GRADE: low quality evidence. Is there any evidence that hyperosmolar fluids have different efficacy (more or less effective) in reducing ICP? Studies were too heterogeneous to be combined in an overall body of evidence.

36 Mannitol HS

37 ICP REDUCTION mmhg ICP reduction after mannitol (low correlation) ICP REDUCTION mmhg ICP reduction after hypertonic saline (low correlation) Mannitol and HS for ICP treatment in TBI - Metaregression 35 Intercept = Q = Intercept = slope = p = 7.4e 09 Q = I 2 = 0 95% CI: 0 69 slope = I 2 = p = 1.496e 12 95% CI: Initial ICP mmhg INITIAL ICP mmhg Initial ICP mmhg

38 Severe traumatic brain injury: targeted management in the intensive care unit. The Lancet Neurology 2017; 16:

39 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233

40 Cnossen MC, CENTER-TBI investigators. Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 2017; 21: 233

41 STAGE 1 Mechanical ventilation Sedation Analgesia with or without paralysis Head of bed elevated to 30 degrees. Intravenous fluids with or without inotropes for MAP > 80 mm Hg. Opt: Ventriculostomy with or without CSF drainage. Opt: Surgical removal of space-occupying lesions Control Group Stage 2: Add Mannitol, Hypertonic saline, Inotropes to maintain cerebral perfusion pressure >60 mmhg Intracranial pressure >20 mmhg 5min within 10 days after injury Hypothermia Group Add stage 2 treatments only if needed Continued medical care. Barbiturate therapy with processed EEG monitoring. Decompressive craniectomy. Further surgical intervention if required Continued medical care. Barbiturate therapy with processed EEG monitoring. Decompressive craniectomy. Further surgical intervention if required Andrews, P. J. D., et al. (2015). Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England Journal of Medicine, 373(25),

42 Andrews, P. J. D., Sinclair, H. L., Rodriguez, A., Harris, B. A., Battison, C. G., Rhodes, J. K. J., et al. (2015). Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England Journal of Medicine, 373(25),

43 The adjusted common odds ratio for the GOS-E score was 1.53 (95% confidence interval, 1.02 to 2.30; P=0.04), indicating a worse outcome in the hypothermia group than in the control group. A favourable outcome (GOS-E score of 5 to 8, indicating moderate disability or good recovery) occurred in 26% of the patients in the hypothermia group and in 37% of the patients in the control group (P=0.03). Andrews, P. J. D., Sinclair, H. L., Rodriguez, A., Harris, B. A., Battison, C. G., Rhodes, J. K. J., et al. (2015). Hypothermia for Intracranial Hypertension after Traumatic Brain Injury. The New England Journal of Medicine, 373(25),

44 Implication for clinical practice NO HT in patients with intracranial hypertension that can be managed with stage 1 and 2 medical treatments. In patients with TBI who have severe intracranial hypertension, i.e., an ICP refractory to all stage 2 treatments before initiation of HT, the use of therapeutic HT when few alternatives remain, may be the single potential remaining indication for HT.

45 ICP > 20 mmhg, 15 minutes/1hr, despite optimized first-tier interventions. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med 2011;:

46 Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med 2011;:

47 Stage 1 Initial treatment measures Ventilation Sedation Analgesia ± Paralysis Nurse head up Monitoring CVP ICP>25 mmhg Stage 2 OPTIONS: Ventriculostomy Inotropes Mannitol Hypertonic saline Loop diuretics Steroids Hypothermia 34-36ºC BARBITURATES NOT PERMITTED ICP>25 mmhg 1-12 hours post start stage 2 RESCUEicp Trial Arterial line ICP Continued Medical treatment * (stage 2 options) + barbiturates permitted Decompressive craniectomy** + continued medical treatment (stage 2 options) Medical 4-6 h Surgical Stage 3 Randomise *If continued medical treatment is drawn no decompressive surgery will be performed at that time. However, decompressive surgery may be performed later if the patient deteriorates with an ICP > 40mmHg and compromised CPP Hutchinson PJ, RESCUEicp **If decompressive Trial Collaborators. craniectomy is Trial drawn of barbiturates Decompressive should Craniectomy not be administrated for Traumatic at that time. Intracranial However, Hypertension. barbiturates may N Engl J Med 2016; 375: be given later if the patient deteriorates with an ICP > 40mmHg and compromised CPP

48 6 months 12 months Hutchinson PJ, RESCUEicp Trial Collaborators. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 2016; 375:

49 For every 100 patients treated with DC rather than medical intent, 22 more survivors (CI 95% 13-31) C I 95% Vegetative Lower SD Upper SD Lower MD Lower GR 3 1-6

50

51 Intro Thresholds Treating HICP Conclusions

52 Take home messages High ICP is associated with negative outcome and has to be treated Thresholds need to keep in consideration intensity and time of exposure Therapies need to be order accordingly to tehr risk/benefit ratio Extreme therapies need to be limited to sicker patients