Multimodal monitoring to individualize care in TBI

Transcription

1 Multimodal monitoring to individualize care in TBI Critical Care Canada Forum 2017 October 4 th, 2017 Donald Griesdale MD MPH Associate Professor Department of Anesthesiology, Pharmacology & Therapeutics Divisions of Critical Care Medicine & Neurology University of British Columbia

2 I have nothing to disclose

3 Patient 1 Patient 2 Patient 3 Severe TBI

4 Culture change needs champions

5 VGH TBI Protocol Cerebral Autoregulation ICP monitor Art line ICM+ monitoring Multimodal monitoring PbO2 Cerebral oxygenation Licox PbO2

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7 Measure of blood flow 1) Brain oxygen monitor (PbtO2) 2) ICP Catheter Pressure Cerebral Autoregulation

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9 ICM+ Monitoring Platform

10 VGH TBI Protocol Cerebral Autoregulation ICP monitor Art line ICM+ monitoring Multimodal monitoring PbO2 Cerebral oxygenation Licox PbO2

11 100 CBV Problem: generalized interventions CBF Zone of autoregulation CPP ICP

12 100 Problem: generalized interventions CBF Zone of autoregulation CPP TBI ICP 1. Stroke 2001; 32: Acta Anaesthesiol Scand 1996;40:1149

13 PRx Problem: generalized interventions CBF ICP CPP OPT CPP

14 +0.6 PRx ICP CPP PRx

15 Autoregulation at the bedside Problem: generalized interventions 1:30 am Levo 5 mcg/min ICP ICP 1:32 am Levo 7 mcg/min ICP ICP 1:35 am Levo 8 mcg/min ICP ICP 1:37 am Levo 8 mcg/min 1:37 am Levo 8 mcg/min 1:40 am Levo 10 mcg/min

16 Stock-free-images.net

17 45yo previously healthy male in MVC Initial vitals by EHS: SBP 80 SaO2 90% GCS 3 Prolonged extrication (30 minutes)

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22 ICP monitor or not?

23 SjO2 42% CBF BTF SjO2 66% Optimal CPP 82.5 mmhg CPP

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27 VGH TBI Protocol Cerebral Autoregulation ICP monitor Art line ICM+ monitoring Multimodal monitoring PbO2 Cerebral oxygenation Licox PbO2

28 Assessment of cerebral blood flow Insert on the non-injured side Does not actually measure intracellular hypoxia

29 PbO2 is a measure of CBF under normoxia

30 35yo male, fell from standing Initially GCS 3 Left pupil 7 mm and dilated Right pupil 4mm and reactive Absent motor function in all 4 extremities

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32 CPP ICP PRx PbO 2 20

33 J Neurosurg 2010;113:571

34 BOOST II Trial Problem: generalized interventions Phase 2, multicentre, randomized control trial (feasibility study) ICP / CPP management alone compared to ICP / CPP + PbO 2 (> 20mmHg) Primary outcome Percentage of time with PbO2 < 20mmHg ICP / CPP group: 0.44 ICP / CPP + PbO2 group 0.14 Improved clinical outcomes? BOOST - III

35 1. Individualize patient care decisions 2. We recommend the continuous assessment & monitoring of ICP and CPP using a structured protocol 3. We suggest that monitoring and assessment of autoregulation may be useful in broad targeting of CPP management 4. We recommend monitoring brain oxygen in patients with or at risk of cerebral ischemia and/or hypoxia 5. It is difficult to demonstrate that any single monitor or combination of monitors has a positive effect on outcome, since outcome is influenced by the therapeutic plan driven by monitoring, not by monitoring itself ICM published online 2014

36 Total Cohort Problem: generalized interventions (n=113) Age in years, mean (SD) 39 (2) Male gender, n(%) 87 (77) Admission hypotension, n(%) 40 (35) Admission hypoxemia, n(%) 26 (23) Glasgow Coma Scale median motor score (IQR) 3 (1 4) One pupil non-reactive, n(%) 33 (29) Mechanism of injury, n(%) Motor vehicle or motor cycle accident 34 (30) Accidental fall 45 (40) Pedestrian or cyclist struck 24 (21) Other 10 (9) Rotterdam score, median (IQR) 3 (3 4) SD = standard deviation; IQR = interquartile range

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40 60% 37%

41 TBI protocols that reduce detrimental variability are important Protocols need to allow changes in management depending on the underlying cerebral physiology Autoregulation monitoring using PRx allows titration of cerebral perfusion pressure allows optimization of cerebral oxygen delivery Evidence for multimodal monitoring is still limited Implementation of a consolidated TBI program requires multidisciplinary champions and culture change

42 23 year old female, professional freestyle skier Undergoes a fall on the half pipe at Whistler (April 5 th ) Intubated on scene and transferred via Helicopter to VGH Initial examination: E1, Vt, M2 MRI = Grade 3 Diffuse Axonal Injury (brainstem involvement)

43 CRASH & IMPACT TBI Prognosis Predictor 6 month mortality = 54% 6 month unfavourable outcome = 81%

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45 Our patients All of the nurses and physicians of the intensive care unit Dr. Mypinder Sekhon (neurointensivist) Ms. Denise Foster Drs. Peter Gooderham & Brian Toyota (neurosurgery) Neurosurgical residents Dr. George Isac (Medical director, intensive care) Jackson Lam (Patient Services Manager, intensive care) Dr. Dean Chittock (Senior Medical Director) Vivian Eliopoulos (COO, VCH)

46 Thank You