Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen–directed therapy

Clinical article

Pradeep K. Narotam M.D., M.M.E.D.1,2,3, John F. Morrison M.S., M.D.2,3, and Narendra Nathoo M.D., Ph.D.2,3,4
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  • 1 Union Hospital Neuroscience, Terre Haute, Indiana;
  • | 2 Divisions of Neurosurgery and
  • | 3 Trauma, Creighton University Medical Center, Omaha, Nebraska; and
  • | 4 Alegent Health Neuroscience Specialists, Council Bluffs, Iowa
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Object

Cerebral ischemia is the leading cause of preventable death in cases of major trauma with severe traumatic brain injury (TBI). Intracranial pressure (ICP) control and cerebral perfusion pressure (CPP) manipulation have significantly reduced the mortality but not the morbidity rate in these patients. In this study, the authors describe their 5-year experience with brain tissue oxygen (PbtO2) monitoring, and the effect of a brain tissue oxygen–directed critical care guide (PbtO2-CCG) on the 6-month clinical outcome (based on the 6-month Glasgow Outcome Scale score) in patients with TBIs.

Methods

One hundred thirty-nine patients admitted to Creighton University Medical Center with major traumatic injuries (Injury Severity Scale [ISS] scores ≥ 16) and TBI underwent prospective evaluation. All patients were treated with a PbtO2-CCG to maintain a brain oxygen level > 20 mm Hg, and control ICP < 20 mm Hg. The role of demographic, clinical, and imaging parameters in the identification of patients at risk for cerebral hypooxygenation and the influence of hypooxygenation on clinical outcome were recorded. Outcomes were compared with those in a historical ICP/CPP patient cohort. Subgroup analysis of severe TBI was performed and compared to data reported in the Traumatic Coma Data Bank.

Results

The majority of injuries were sustained in motor vehicle crashes (63%), and diffuse brain injury was the most common abnormality (58%). Mechanism of injury, severity of TBI, pathological entity, neuroimaging results, and trauma indices were not predictive of ischemia. Factors affecting death included gunshot injury, poor trauma indices, subarachnoid hemorrhage, and coma. After standard resuscitation, 65% of patients had an initially low PbtO2. Data are presented as means ± SDs. Treatment with the PbtO2-CCG resulted in a 44% improvement in mean PbtO2 (16.21 ± 12.30 vs 23.65 ± 14.40 mm Hg; p < 0.001), control of ICP (mean 12.76 ± 6.42 mm Hg), and the maintenance of CPP (mean 76.13 ± 15.37 mm Hg). Persistently low cerebral oxygenation was seen in 37% of patients at 2 hours, 31% at 24 hours, and 18% at 48 hours of treatment. Thus elevated ICP and a persistent low PbtO2 after 2 hours represented increasing odds of death (OR 14.3 at 48 hours). Survivors and patients with good outcomes generally had significantly higher mean daily PbtO2 and CPP values compared to nonsurvivors. Polytrauma, associated with higher ISS scores, presented an increased risk of vegetative outcome (OR 9.0). Compared to the ICP/CPP cohort, the mean Glasgow Outcome Scale score at 6 months in patients treated with PbtO2-CCG was higher (3.55 ± 1.75 vs 2.71 ± 1.65, p < 0.01; OR for good outcome 2.09, 95% CI 1.031–4.24) as was the reduction in mortality rate (25.9 vs 41.50%; relative risk reduction 37%), despite higher ISS scores in the PbtO2 group (31.6 ± 13.4 vs 27.1 ± 8.9; p < 0.05). Subgroup analysis of severe closed TBI revealed a significant relative risk reduction in mortality rate of 37–51% compared with the Traumatic Coma Data Bank data, and an increased OR for good outcome especially in patients with diffuse brain injury without mass lesions (OR 4.9, 95% CI 2.9–8.4).

Conclusions

The prevention and aggressive treatment of cerebral hypooxygenation and control of ICP with a PbtO2-directed protocol reduced the mortality rate after TBI in major trauma, but more importantly, resulted in improved 6-month clinical outcomes over the standard ICP/CPP-directed therapy at the authors' institution.

Abbreviations used in this paper:

AANS = American Association of Neurological Surgeons; BTF = Brain Trauma Foundation; CBF = cerebral blood flow; CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ICU = intensive care unit; ISS = Injury Severity Scale; NS = not significant; PbtO2 = brain tissue partial pressure of oxygen; PbtO2-CCG = brain tissue oxygen–directed critical care guide; RR = relative risk; RTS = Revised Trauma Score; TBI = traumatic brain injury; TCDB = Traumatic Coma Data Bank.

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  • 1

    Andrews PJ: Cerebral perfusion pressure and brain ischaemia: can one size fit all?. Crit Care 9:638639, 2005

  • 2

    Atzema C, , Mower WR, , Hoffman JR, , Holmes JF, , Killian AJ, & Wolfson AB: Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma. J Trauma 60:10101017, 2006

    • Search Google Scholar
    • Export Citation
  • 3

    Balestreri M, , Czosnyka M, , Hutchinson P, , Steiner LA, , Hiler M, & Smielewski P, et al.: Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 4:813, 2006

    • Search Google Scholar
    • Export Citation
  • 4

    Bardt TF, , Unterberg AW, , Hartl R, , Kiening KL, , Schneider GH, & Lanksch WR: Monitoring of brain tissue PO2 in traumatic brain injury: effect of cerebral hypoxia on outcome. Acta Neurochir Suppl 71:153156, 1998

    • Search Google Scholar
    • Export Citation
  • 5

    Becker DP, , Miller JD, , Ward JD, , Greenberg RP, , Young HF, & Sakalas R: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:491502, 1977

    • Search Google Scholar
    • Export Citation
  • 6

    Bruzzone P, , Dionigi R, , Bellinzona G, , Imberti R, & Stocchetti N: Effects of cerebral perfusion pressure on brain tissue PO2 in patients with severe head injury. Acta Neurochir Suppl 71:111113, 1998

    • Search Google Scholar
    • Export Citation
  • 7

    Bulger EM, , Nathens AB, , Rivara FP, , Moore M, , MacKenzie EJ, & Jurkovich GJ: Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med 30:18701876, 2002

    • Search Google Scholar
    • Export Citation
  • 8

    Celli P, , Fruin A, & Cervoni L: Severe head trauma. Review of the factors influencing the prognosis. Minerva Chir 52:14671480, 1997

  • 9

    Chesnut RM: Secondary brain insults after head injury: clinical perspectives. New Horiz 3:366375, 1995

  • 10

    Coles JP: Regional ischemia after head injury. Curr Opin Crit Care 10:120125, 2004

  • 11

    Coles JP, , Steiner LA, , Johnston AJ, , Fryer TD, , Coleman MR, & Smieleweski P, et al.: Does induced hypertension reduce cerebral ischaemia within the traumatized human brain?. Brain 127:24792490, 2004

    • Search Google Scholar
    • Export Citation
  • 12

    Cormio M, , Valadka AB, & Robertson CS: Elevated jugular venous oxygen saturation after severe head injury. J Neurosurg 90:915, 1999

  • 13

    Cremer OL, , van Dijk GW, , van Wensen E, , Brekelmans GJ, , Moons KG, & Leenen LP, et al.: Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med 33:22072213, 2005

    • Search Google Scholar
    • Export Citation
  • 14

    Demetriades D, , Kuncir E, , Brown CV, , Martin M, , Salim A, & Rhee P, et al.: Early prediction of mortality in isolated head injury patients: a new predictive model. J Trauma 61:868872, 2006

    • Search Google Scholar
    • Export Citation
  • 15

    Dings J, , Meixensberger J, , Jager A, & Roosen K: Clinical experience with 118 brain tissue oxygen partial pressure catheter probes. Neurosurgery 43:10821095, 1998

    • Search Google Scholar
    • Export Citation
  • 16

    Fandino J, , Stocker R, , Prokop S, , Trentz O, & Imhof HG: Cerebral oxygenation and systemic trauma-related factors determining neurological outcome after brain injury. J Clin Neurosci 7:226233, 2000

    • Search Google Scholar
    • Export Citation
  • 17

    Filippi R, , Reisch R, , Mauer D, & Perneczky A: Brain tissue pO2 related to SjvO2, ICP, and CPP in severe brain injury. Neurosurg Rev 23:9497, 2000

    • Search Google Scholar
    • Export Citation
  • 18

    Haitsma IK, & Maas AI: Advanced monitoring in the intensive care unit: brain tissue oxygen tension. Curr Opin Crit Care 8:115120, 2002

  • 19

    Hong WC, , Tu YK, , Chen YS, , Lien LM, & Huang SJ: Subdural intracranial pressure monitoring in severe head injury: clinical experience with the Codman MicroSensor. Surg Neurol 66:2 Suppl S8S13, 2006

    • Search Google Scholar
    • Export Citation
  • 20

    Huang SJ, , Hong WC, , Han YY, , Chen YS, , Wen CS, & Tsai YS, et al.: Clinical outcome of severe head injury using three different ICP and CPP protocol-driven therapies. J Clin Neurosci 13:818822, 2006

    • Search Google Scholar
    • Export Citation
  • 21

    Jaeger M, , Soehle M, , Schuhmann MU, , Winkler D, & Meixensberger J: Correlation of continuously monitored regional cerebral blood flow and brain tissue oxygen. Acta Neurochir (Wien) 147:5156, 2005

    • Search Google Scholar
    • Export Citation
  • 22

    Johnston AJ, , Steiner LA, , Coles JP, , Chatfield DA, , Fryer TD, & Smielewski P, et al.: Effect of cerebral perfusion pressure augmentation on regional oxygenation and metabolism after head injury. Crit Care Med 33:189195, 2005

    • Search Google Scholar
    • Export Citation
  • 23

    Kiening KL, , Hartl R, , Unterberg AW, , Schneider GH, , Bardt T, & Lanksch WR: Brain tissue pO2-monitoring in comatose patients: implications for therapy. Neurol Res 19:233240, 1997

    • Search Google Scholar
    • Export Citation
  • 24

    Kiening KL, , Schneider GH, , Bardt TF, , Unterberg AW, & Lanksch WR: Bifrontal measurements of brain tissue-PO2 in comatose patients. Acta Neurochir Suppl 71:172173, 1998

    • Search Google Scholar
    • Export Citation
  • 25

    Kiening KL, , Unterberg AW, , Bardt TF, , Schneider GH, & Lanksch WR: Monitoring of cerebral oxygenation in patients with severe head injuries: brain tissue PO2 versus jugular vein oxygen saturation. J Neurosurg 85:751757, 1996

    • Search Google Scholar
    • Export Citation
  • 26

    Lane PL, , Skoretz TG, , Doig G, & Girotti MJ: Intracranial pressure monitoring and outcomes after traumatic brain injury. Can J Surg 43:442448, 2000

    • Search Google Scholar
    • Export Citation
  • 27

    Manley G, , Knudson MM, , Morabito D, , Damron S, , Erickson V, & Pitts L: Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg 136:11181123, 2001

    • Search Google Scholar
    • Export Citation
  • 28

    Manley GT, , Hemphill JC, , Morabito D, , Derugin N, , Erickson V, & Pitts LH, et al.: Cerebral oxygenation during hemorrhagic shock: perils of hyperventilation and the therapeutic potential of hypoventilation. J Trauma 48:10251032, 2000

    • Search Google Scholar
    • Export Citation
  • 29

    Marshall LF, & Eisenberg HM: ICP monitoring in severe head injury. J Neurosurg 67:952953, 1987

  • 30

    Marshall LF, , Eisenberg HM, , Jane JA, , Luerssen TG, , Marmarou A, & Foulkes MA: The outcome of severe closed head injury. J Neurosurg 75:Suppl S28S36, 1991

    • Search Google Scholar
    • Export Citation
  • 31

    Marshall LF, , Maas AI, , Marshall SB, , Bricolo A, , Fearnside M, & Iannotti F, et al.: A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury. J Neurosurg 89:519525, 1998

    • Search Google Scholar
    • Export Citation
  • 32

    Marshall LF, , Marshall SB, , Klauber MR, , Van Berkum Clark M, , Eisenberg H, & Jane JA, et al.: The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 9:1 Suppl S287S292, 1992

    • Search Google Scholar
    • Export Citation
  • 33

    Marshall LF, , Smith RW, & Shapiro HM: The outcome with aggressive treatment in severe head injuries. Part I: the significance of intracranial pressure monitoring. J Neurosurg 50:2025, 1979

    • Search Google Scholar
    • Export Citation
  • 34

    Marshall LF, , Smith RW, & Shapiro HM: The outcome with aggressive treatment in severe head injuries. Part II: acute and chronic barbiturate administration in the management of head injury. J Neurosurg 50:2630, 1979

    • Search Google Scholar
    • Export Citation
  • 35

    McDonagh M, , Helfand M, , Carson S, & Russman BS: Hyperbaric oxygen therapy for traumatic brain injury: a systematic review of the evidence. Arch Phys Med Rehabil 85:11981204, 2004

    • Search Google Scholar
    • Export Citation
  • 36

    Menzel M, , Doppenberg EM, , Zauner A, , Soukup J, , Reinert MM, & Bullock R: Increased inspired oxygen concentration as a factor in improved brain tissue oxygenation and tissue lactate levels after severe human head injury. J Neurosurg 91:110, 1999

    • Search Google Scholar
    • Export Citation
  • 37

    Miller JD, , Butterworth JF, , Gudeman SK, , Faulkner JE, , Choi SC, & Selhorst JB, et al.: Further experience in the management of severe head injury. J Neurosurg 54:289299, 1981

    • Search Google Scholar
    • Export Citation
  • 38

    Narotam PK, , Burjonrappa SC, , Raynor SC, , Rao M, & Taylon C: Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome. J Pediatr Surg 41:505513, 2006

    • Search Google Scholar
    • Export Citation
  • 39

    Narotam PK, , Puri V, , Roberts JM, , Taylon C, , Vora Y, & Nathoo N: Management of hypertensive emergencies in acute brain disease: evaluation of the treatment effects of intravenous nicardipine on cerebral oxygenation. J Neurosurg 109:10651074, 2008

    • Search Google Scholar
    • Export Citation
  • 40

    Neugebauer E, , Lefering R, & Noth J: New perspectives in neurotrauma research. Restor Neurol Neurosci 14:8384, 1999

  • 41

    Ng I, , Lew TW, , Yeo TT, , Seow WT, , Tan KK, & Ong PL, et al.: Outcome of patients with traumatic brain injury managed on a standardised head injury protocol. Ann Acad Med Singapore 27:332339, 1998

    • Search Google Scholar
    • Export Citation
  • 42

    Overgaard J, & Tweed WA: Cerebral circulation after head injury. Part 4: Functional anatomy and boundary-zone flow deprivation in the first week of traumatic coma. J Neurosurg 59:439446, 1983

    • Search Google Scholar
    • Export Citation
  • 43

    Palmer S, , Bader MK, , Qureshi A, , Palmer J, , Shaver T, & Borzatta M, et al.: The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. American Associations for Neurologic Surgeons. J Trauma 50:657664, 2001

    • Search Google Scholar
    • Export Citation
  • 44

    Patel HC, , Bouamra O, , Woodford M, , King AT, , Yates DW, & Lecky FE: Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 366:15381544, 2005

    • Search Google Scholar
    • Export Citation
  • 45

    Reinert M, , Barth A, , Rothen HU, , Schaller B, , Takala J, & Seiler RW: Effects of cerebral perfusion pressure and increased fraction of inspired oxygen on brain tissue oxygen, lactate and glucose in patients with severe head injury. Acta Neurochir (Wien) 145:341350, 2003

    • Search Google Scholar
    • Export Citation
  • 46

    Rondina C, , Videtta W, , Petroni G, , Lujan S, , Schoon P, & Mori LB, et al.: Mortality and morbidity from moderate to severe traumatic brain injury in Argentina. J Head Trauma Rehabil 20:368376, 2005

    • Search Google Scholar
    • Export Citation
  • 47

    Sahuquillo J, , Amoros S, , Santos A, , Poca MA, , Panzardo H, & Dominguez L, et al.: Does an increase in cerebral perfusion pressure always mean a better oxygenated brain? A study in head-injured patients. Acta Neurochir Suppl 76:457462, 2000

    • Search Google Scholar
    • Export Citation
  • 48

    Sarrafzadeh AS, , Kiening KL, , Bardt TF, , Schneider GH, , Unterberg AW, & Lanksch WR: Cerebral oxygenation in contusioned vs. nonlesioned brain tissue: monitoring of PtiO2 with Licox and Paratrend. Acta Neurochir Suppl 71:186189, 1998

    • Search Google Scholar
    • Export Citation
  • 49

    Sarrafzadeh AS, , Kiening KL, , Callsen TA, & Unterberg AW: Metabolic changes during impending and manifest cerebral hypoxia in traumatic brain injury. Br J Neurosurg 17:340346, 2003

    • Search Google Scholar
    • Export Citation
  • 50

    Sarrafzadeh AS, , Peltonen EE, , Kaisers U, , Kuchler I, , Lanksch WR, & Unterberg AW: Secondary insults in severe head injury—do multiply injured patients do worse?. Crit Care Med 29:11161123, 2001

    • Search Google Scholar
    • Export Citation
  • 51

    Schneider GH, , Sarrafzadeh AS, , Kiening KL, , Bardt TF, , Unterberg AW, & Lanksch WR: Influence of hyperventilation on brain tissue-PO2, PCO2, and pH in patients with intracranial hypertension. Acta Neurochir Suppl 71:6265, 1998

    • Search Google Scholar
    • Export Citation
  • 52

    Signorini DF, & Alderson P: Therapeutic hypothermia for head injury. Cochrane Database Syst Rev 2:CD001048, 2000

  • 53

    Stiefel MF, , Spiotta A, , Gracias VH, , Garuffe AM, , Guillamondegui O, & Maloney-Wilensky E, et al.: Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring. J Neurosurg 103:805811, 2005

    • Search Google Scholar
    • Export Citation
  • 54

    Stiefel MF, , Udoetuk JD, , Spiotta AM, , Gracias VH, , Goldberg A, & Maloney-Wilensky E, et al.: Conventional neurocritical care and cerebral oxygenation after traumatic brain injury. J Neurosurg 105:568575, 2006

    • Search Google Scholar
    • Export Citation
  • 55

    Stocchetti N, , Chieregato A, , De Marchi M, , Croci M, , Benti R, & Grimoldi N: High cerebral perfusion pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions. Acta Neurochir Suppl 71:162165, 1998

    • Search Google Scholar
    • Export Citation
  • 56

    Stocchetti N, , Penny KI, , Dearden M, , Braakman R, , Cohadon F, & Iannotti F, et al.: Intensive care management of head-injured patients in Europe: a survey from the European Brain Injury Consortium. Intensive Care Med 27:400406, 2001

    • Search Google Scholar
    • Export Citation
  • 57

    Teasdale G, & Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:8184, 1974

  • 58

    Valadka AB, , Gopinath SP, , Contant CF, , Uzura M, & Robertson CS: Relationship of brain tissue PO2 to outcome after severe head injury. Crit Care Med 26:15761581, 1998

    • Search Google Scholar
    • Export Citation
  • 59

    van den Brink WA, , van Santbrink H, , Avezaat CJ, , Hogesteeger C, , Jansen W, & Kloos LM, et al.: Monitoring brain oxygen tension in severe head injury: the Rotterdam experience. Acta Neurochir Suppl 71:190194, 1998

    • Search Google Scholar
    • Export Citation
  • 60

    van den Brink WA, , van Santbrink H, , Steyerberg EW, , Avezaat CJ, , Suazo JA, & Hogesteeger C, et al.: Brain oxygen tension in severe head injury. Neurosurgery 46:868876, 2000

    • Search Google Scholar
    • Export Citation
  • 61

    van Santbrink H, , Maas AI, & Avezaat CJ: Continuous monitoring of partial pressure of brain tissue oxygen in patients with severe head injury. Neurosurgery 38:2131, 1996

    • Search Google Scholar
    • Export Citation
  • 62

    van Santbrink H, , Schouten JW, , Steyerberg EW, , Avezaat CJ, & Maas AI: Serial transcranial Doppler measurements in traumatic brain injury with special focus on the early posttraumatic period. Acta Neurochir (Wien) 144:11411149, 2002

    • Search Google Scholar
    • Export Citation
  • 63

    van Santbrink H, , van den Brink WA, , Steyerberg EW, , Carmona Suazo JA, , Avezaat CJ, & Maas AI: Brain tissue oxygen response in severe traumatic brain injury. Acta Neurochir (Wien) 145:429438, 2003

    • Search Google Scholar
    • Export Citation
  • 64

    Visvanathan R: Severe head injury management in a general surgical department. Aust N Z J Surg 64:527529, 1994

  • 65

    Vukic M, , Negovetic L, , Kovac D, , Ghajar J, , Glavic Z, & Gopcevic A: The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome. Acta Neurochir (Wien) 141:12031208, 1999

    • Search Google Scholar
    • Export Citation
  • 66

    Yang X, , Yang S, , Wang M, & Gao Y: Prospective survey on neurosurgical intensive care for patients with severe head injury. Chin J Traumatol 4:9396, 2001

    • Search Google Scholar
    • Export Citation
  • 67

    Zhi DS, , Zhang S, & Zhou LG: Continuous monitoring of brain tissue oxygen pressure in patients with severe head injury during moderate hypothermia. Surg Neurol 52:393396, 1999

    • Search Google Scholar
    • Export Citation

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