Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma

Tim Howells Ph.D. 1 , Kristin Elf M.D. 1 , Patricia A. Jones M.App.Sc. 1 , Elisabeth Ronne-Engström M.D., Ph.D. 1 , Ian Piper Ph.D. 1 , Pelle Nilsson M.D., Ph.D. 1 , Peter Andrews M.D., Ph.D. 1 , and Per Enblad M.D., Ph.D. 1
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  • 1 Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden; Department of Clinical Physics, Southern General Hospital, Glasgow; Child Life and Health, University of Edinburgh and Royal Hospital for Sick Children; and Department of Anesthesiology, Western General Hospital, Edinburgh, Scotland
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Object. The aim of this study was to compare the effects of two different treatment protocols on physiological characteristics and outcome in patients with brain trauma. One protocol was primarily oriented toward reducing intracranial pressure (ICP), and the other primarily on maintaining cerebral perfusion pressure (CPP).

Methods. A series of 67 patients in Uppsala were treated according to a protocol aimed at keeping ICP less than 20 mm Hg and, as a secondary target, CPP at approximately 60 mm Hg. Another series of 64 patients in Edinburgh were treated according to a protocol aimed primarily at maintaining CPP greater than 70 mm Hg and, secondarily, ICP less than 25 mm Hg for the first 24 hours and 30 mm Hg subsequently.

The ICP and CPP insults were assessed as the percentage of monitoring time that ICP was greater than or equal to 20 mm Hg and CPP less than 60 mm Hg, respectively. Pressure reactivity in each patient was assessed based on the slope of the regression line relating mean arterial blood pressure (MABP) to ICP. Outcome was analyzed at 6 months according to the Glasgow Outcome Scale (GOS).

The prognostic value of secondary insults and pressure reactivity was determined using linear methods and a neural network. In patients treated according to the CPP-oriented protocol, even short durations of CPP insults were strong predictors of death. In patients treated according to the ICP-oriented protocol, even long durations of CPP insult—mostly in the range of 50 to 60 mm Hg—were significant predictors of favorable outcome (GOS Score 4 or 5). Among those who had undergone ICP-oriented treatment, pressure-passive patients (MABP/ICP slope ≥ 0.13) had a better outcome. Among those who had undergone CPP-oriented treatment, the more pressure-active (MABP/ICP slope < 0.13) patients had a better outcome.

Conclusions. Based on data from this study, the authors concluded that ICP-oriented therapy should be used in patients whose slope of the MABP/ICP regression line is at least 0.13, that is, in pressure-passive patients. If the slope is less than 0.13, then hypertensive CPP therapy is likely to produce a better outcome.

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Contributor Notes

Address reprint requests to: Tim Howells, Ph.D., Department of Neurosurgery, University Hospital, 751 85 Uppsala, Sweden. email: timothy.howells@lul.se.
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