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
I have nothing to disclose
Patient 1 Patient 2 Patient 3 Severe TBI
Culture change needs champions
VGH TBI Protocol Cerebral Autoregulation ICP monitor Art line ICM+ monitoring Multimodal monitoring PbO2 Cerebral oxygenation Licox PbO2
Measure of blood flow 1) Brain oxygen monitor (PbtO2) 2) ICP Catheter Pressure Cerebral Autoregulation
ICM+ Monitoring Platform
VGH TBI Protocol Cerebral Autoregulation ICP monitor Art line ICM+ monitoring Multimodal monitoring PbO2 Cerebral oxygenation Licox PbO2
100 CBV Problem: generalized interventions CBF 75 50 25 Zone of autoregulation 25 50 75 100 125 150 175 CPP ICP
100 Problem: generalized interventions CBF 75 50 25 Zone of autoregulation 25 50 75 100 125 150 175 CPP TBI ICP 1. Stroke 2001; 32: 128 32 2. Acta Anaesthesiol Scand 1996;40:1149
PRx 100 1.0 Problem: generalized interventions CBF 75 50 25 ICP 0.5 0-0.5 CPP OPT 25 50 75 100 125 150 175 CPP
+0.6 PRx 0-0.2 ICP CPP PRx
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
Stock-free-images.net
45yo previously healthy male in MVC Initial vitals by EHS: SBP 80 SaO2 90% GCS 3 Prolonged extrication (30 minutes)
ICP monitor or not?
+0.6 0-0.2 SjO2 42% CBF BTF SjO2 66% Optimal CPP 82.5 mmhg 50 60 70 80 90 100 110 120 130 CPP
VGH TBI Protocol Cerebral Autoregulation ICP monitor Art line ICM+ monitoring Multimodal monitoring PbO2 Cerebral oxygenation Licox PbO2
Assessment of cerebral blood flow Insert on the non-injured side Does not actually measure intracellular hypoxia
PbO2 is a measure of CBF under normoxia
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
CPP ICP PRx 100 20 PbO 2 20
J Neurosurg 2010;113:571
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
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
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
60% 37%
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
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)
CRASH & IMPACT TBI Prognosis Predictor 6 month mortality = 54% 6 month unfavourable outcome = 81%
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)
Thank You