Current bedside monitors of brain blood flow and oxygen delivery
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- Beverly Bates
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1 24. Brain Chemistry
2 Current bedside monitors of brain blood flow and oxygen delivery Global monitors Cannot detect regional abnormalities Local monitors Sample only a small region of the brain and highly dependent on accurate placement Thanks to Mr.P.Hutchinson
3 Brain probes Peter Hutchinson, 2000
4 Neurotrend Sensor Technology 17mm Temperature PO 2 <0.5mm PCO 2 ph Thanks to Mr.P.Hutchinson
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6 PbO 2 (kpa) Brain tissue oxygenation and jugular bulb saturation (A.Gupta, Cambridge, U.K.) Changes in PbO 2 with SjvO 2 in areas with no focal pathology r 2 SjvO 2 (%) Anesth Analg 1999; 88(3):
7 Long-term brain tissue oxygenation monitoring kpa
8 Overall, there seems to be no correlation between PbtiO2 and ICP /CPP
9 If you are lucky and click on more coherent area, correlation sometimes appears. Is it physiology or click phenomenon?
10 Transient changes in brain tissue oxygenation seem to follow changes in CPP Plateau wave of ICP Arterial hypertension
11 Arterial hypotension Hyperaemia. Exception?
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13 We could not find any correlation between Orx and PRx
14 Near Infrared spectroscopy: Basic Principle LIGHT IN ( nm) Fixed Scattering and Absorbing Medium (melanin, bilirubin, bone, water, lipid, etc ) Oxygenated Haemoglobin (HbO 2 ) De-oxygenated Haemoglobin (Hb) Oxidised Cytochrome Oxidase (CtOx) LIGHT OUT Thanks to Dr.K.Brady
15 NIRS Can Trend CBF and CBV Cerebral Oximetry: CBF CMRO 2 HCT SaO 2 BVI: CBV HCT Thanks to Dr.K.Brady
16 Emitter 775nm 810nm 850nm 910nm Principle of NIRO cm Detectors Skin CSF Bone Thanks to Mrs.P.All-Rawi Brain Tissue
17 log attenuation Measurement of TOI a x s ( A d - ) d Diffusion theory model + in vivo experiments = s source/detector distance where a s A d = absorption coefficient = scattering coefficient = attenuation = distance Total Hb & HbO 2 concentration Regression model equation a Total tissue absorption coefficient TOI Thanks to Mrs.P.All-Rawi
18 Hb & HbO 2 Changes during Clamping of Carotid Arteries ECA on ICA on LDF (au) FV (cm/s) Hb ( M) HbO 2 ( M) TOI (%) Al-Rawi PG, Smielewski P, Kirkpatrick PJ. Evaluation of a near-infrared spectrometer (NIRO 300) for the detection of intracranial oxygenation changes in the adult head. Stroke. 2001; 32(11):
19 NIRS measurements Laptop running ICM+ software NIRS Probes Hamamatsu NIRO 200 NIRS is can be easily used longtime and is non-invaisve Smielewski P., Czosnyka M, Steiner L, at al (2005) ICM+ software for on-line analysis of bedside monitoring data after severe head trauma. Acta Neurochir Suppl.;95:43-9 Thanks to M.Ch.Zweifel
20 Plateau waves Thanks to M.Ch.Zweifel
21 Coughing Thanks to M.Ch.Zweifel
22 Change in ventilation and position Thanks to M.Ch.Zweifel
23 NIRS and change in ventilation Thanks to M.Ch.Zweifel
24 NIRS and slow waves Thanks to M.Ch.Zweifel
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28 Data from Porto, TBI, thanks to Dr. Celesta Dias
29 Microdialysis A technique for sampling the extracellular space The microdialysis catheter consists of two concentric tubes separated from the external environment by a semi-permeable membrane Molecules diffuse into the catheter and the fluid can be recovered and assayed for molecules of interest Metabolic intermediaries such as glucose, lactate and pyruvate diffuse out of cells into the extracellular space Thanks to Mr.A.Helmy
30 Schematic of microdialysis catheter tip Extracellular fluid 10 mm Diffusion of molecules across the dialysis membrane Perfusion fluid 0.3 µl/min 0.5mm Microdialysate To collection vial Perfusion fluid 0.3 µl/min Gold closed end (visible on CT) Inner tube Dialysis membrane (PAES) 100 kda MWCO Thanks to Mr.A.Helmy
31 Thanks to Mr.A.Helmy Microdialysis
32 Blood capillary Microdialysis catheter Principles of Microdialysis Glucose Lactate Pyruvate Glycerol Glutamate Thanks to Mr.A.Helmy
33 Microdialysis Parameters Glucose, Lactate, Pyruvate Neuronal metabolic fuels Glutamate Excitatory neurotransmitter Commonest neurotransmitter in the brain Implicated in excitotoxic damage Glycerol Constituent of cellular membrane (phosopholipid) Released following cellular death Thanks to Mr.A.Helmy
34 Lactate / Pyruvate Ratio The balance between lactate and pyruvate provides a measure of the balance between aerobic and anaerobic metabolism at the cellular level The Redox State of the Cell Using the ratio between lactate and pyruvate is required to avoid the confounding effects of glucose availability Thanks to Mr.A.Helmy
35 Summary of Metabolic Changes Glucose Lactate Pyruvate L/P NAD + ADP Hypoxia NAD + NADH ATP Ischemia Lactate Pyruvate Hypoxia Hypoglycemia ATP ATP ATP Citric Acid Cycle Hyperglycemia Thanks to Mr.A.Helmy
36 Interpreting Microdialysis Data Thanks to Mr.A.Helmy
37 Interpreting Microdialysis Data Thanks to Mr.A.Helmy
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39 What does it mean? Microdialysis provides a very sensitive measure of local biochemistry Often precedes changes in ICP An early warning indicator Problems Only reflects biochemistry in a small volume of brain look for concordance with other monitoring What parameters can you manipulate to improve tissue biochemistry? CPP ICP Hyperosmolar agent Hyperoxia Thanks to Mr.A.Helmy
40 Lactate/pyruvate Microdialysis (Peter Hutchinson). PET-microdialysis correlation 50 r=0.69 p= OEF
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44 Messages to take home Brain tissue oxygenation: good for continuous monitoring, correlates with outcome?, local, invasive NIROS: continuous monitoring, more global, two sides, non-invasive, not validated clinically yet, extracranial contamination? Microdialysis: invasive, local, intermittent. Is it clinical or research tool?
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