Object. An intracranial pressure (ICP) monitor, from which cerebral perfusion pressure (CPP) is estimated, is recommended in the care of severe traumatic brain injury (TBI). Nevertheless, optimal ICP and CPP management may not always prevent cerebral ischemia, which adversely influences patient outcome. The authors therefore determined whether the addition of a brain tissue oxygen tension (PO2) monitor in the treatment of TBI was associated with an improved patient outcome.
Methods. Patients with severe TBI (Glasgow Coma Scale [GCS] score < 8) who had been admitted to a Level I trauma center were evaluated as part of a prospective observational database. Patients treated with ICP and brain tissue PO2 monitoring were compared with historical controls matched for age, pathological features, admission GCS score, and Injury Severity Score who had undergone ICP monitoring alone. Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg. Among patients whose brain tissue PO2 was monitored, oxygenation was maintained at levels greater than 25 mm Hg. Twenty-five patients with a mean age of 44 ± 14 years were treated using an ICP monitor alone. Twenty-eight patients with a mean age of 38 ± 18 years underwent brain tissue PO2-directed care. The mean daily ICP and CPP levels were similar in each group. The mortality rate in patients treated using conventional ICP and CPP management was 44%. Patients who also underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25% (p < 0.05).
Conclusions. The use of both ICP and brain tissue PO2 monitors and therapy directed at brain tissue PO2 is associated with reduced patient death following severe TBI.
BullockMRChestnutRMCliftonGGhajarJMarionDWNarayanRKet al: Management and prognosis of severe traumatic brain injury. Part I: Guidelines for the Management of Severe Traumatic Brain Injury.J Neurotrauma17:449–5532000J Neurotrauma 17:
CruzJ: Adverse effects of pentobarbital on cerebral venous oxygenation of comatose patients with acute traumatic brain swelling: relationship to outcome.J Neurosurg85:758–7611996Cruz J: Adverse effects of pentobarbital on cerebral venous oxygenation of comatose patients with acute traumatic brain swelling: relationship to outcome. J Neurosurg 85:
CruzJ: The first decade of continuous monitoring of jugular bulb oxyhemoglobin saturation: management strategies and clinical outcome.Crit Care Med26:344–3511998Cruz J: The first decade of continuous monitoring of jugular bulb oxyhemoglobin saturation: management strategies and clinical outcome. Crit Care Med 26:
DeardenNM: Mechanisms and prevention of secondary brain damage during intensive care.Clin Neuropathol17:221–2281998Dearden NM: Mechanisms and prevention of secondary brain damage during intensive care. Clin Neuropathol 17:
GopinathSPValadkaABUzuraMRobertsonCS: Comparison of jugular venous oxygen saturation and brain tissue PO2 as monitors of cerebral ischemia after head injury.Crit Care Med27:2337–23451999Crit Care Med 27:
MenzelMDoppenbergEMRZaunerASoukupJReinertMMBullockR: Increased inspired oxygen concentration as a factor in improved brain tissue oxygenation and tissue lactate levels after severe human head injury.J Neurosurg91:1–101999J Neurosurg 91:
MuizelaarJPMarmarouAWardJDKontosHAChoiSCBeckerDPet al: Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial.J Neurosurg75:731–7391991J Neurosurg 75:
ProcaccioFStocchettiNCiterioGBerardinoMBerettaLDella CorteFet al: Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment.J Neurosurg Sci44:11–182000J Neurosurg Sci 44:
SahuquilloJAmorosSSantosAPocaMAPanzardoHDominguezLet al: Does an increase in cerebral perfusion pressure always mean a better oxygenated brain? A study in head-injured patients.Acta Neurochir Suppl76:457–4622000Acta Neurochir Suppl 76:
StiefelMFHeuerGGSmithMJBloomSMaloney-WilenskyEGradyMSet al: Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension.J Neurosurg101:241–2472004J Neurosurg 101:
ToliasCMReinertMSeilerRGilmanCScharfABullockMR: Normobaric hyperoxia—induced improvement in cerebral metabolism and reduction in intracranial pressure in patients with severe head injury: a prospective historical cohort-matched study.J Neurosurg101:435–4442004J Neurosurg 101:
ValadkaABGoodmanJCGopinathSPUzuraMRobertsonCS: Comparison of brain tissue oxygen tension to microdialysis-based measures of cerebral ischemia in fatally head-injured humans.J Neurotrauma15:509–5191998J Neurotrauma 15: