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

Clinical article

Restricted access

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.

Article Information

Address correspondence to: Pradeep K. Narotam, M.D., 1530 North 7th Street, #106, Terre Haute, Indiana 47807. email:narotam@mac.com.

Please include this information when citing this paper: published online May 22, 2009; DOI: 10.3171/2009.4.JNS081150.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Flow chart of the management algorithm used in 139 patients with head injury and major trauma undergoing PbtO2-directed therapy with mortality analysis. ARDS = adult respiratory distress syndrome; DECRA = decompressive craniectomy; MSOF = multiple system organ failure.

References

1

Andrews PJ: Cerebral perfusion pressure and brain ischaemia: can one size fit all?. Crit Care 9:6386392005

2

Atzema CMower WRHoffman JRHolmes JFKillian AJWolfson AB: Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma. J Trauma 60:101010172006

3

Balestreri MCzosnyka MHutchinson PSteiner LAHiler MSmielewski P: Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 4:8132006

4

Bardt TFUnterberg AWHartl RKiening KLSchneider GHLanksch WR: Monitoring of brain tissue PO2 in traumatic brain injury: effect of cerebral hypoxia on outcome. Acta Neurochir Suppl 71:1531561998

5

Becker DPMiller JDWard JDGreenberg RPYoung HFSakalas R: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:4915021977

6

Bruzzone PDionigi RBellinzona GImberti RStocchetti N: Effects of cerebral perfusion pressure on brain tissue PO2 in patients with severe head injury. Acta Neurochir Suppl 71:1111131998

7

Bulger EMNathens ABRivara FPMoore MMacKenzie EJJurkovich GJ: Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med 30:187018762002

8

Celli PFruin ACervoni L: Severe head trauma. Review of the factors influencing the prognosis. Minerva Chir 52:146714801997

9

Chesnut RM: Secondary brain insults after head injury: clinical perspectives. New Horiz 3:3663751995

10

Coles JP: Regional ischemia after head injury. Curr Opin Crit Care 10:1201252004

11

Coles JPSteiner LAJohnston AJFryer TDColeman MRSmieleweski P: Does induced hypertension reduce cerebral ischaemia within the traumatized human brain?. Brain 127:247924902004

12

Cormio MValadka ABRobertson CS: Elevated jugular venous oxygen saturation after severe head injury. J Neurosurg 90:9151999

13

Cremer OLvan Dijk GWvan Wensen EBrekelmans GJMoons KGLeenen LP: Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med 33:220722132005

14

Demetriades DKuncir EBrown CVMartin MSalim ARhee P: Early prediction of mortality in isolated head injury patients: a new predictive model. J Trauma 61:8688722006

15

Dings JMeixensberger JJager ARoosen K: Clinical experience with 118 brain tissue oxygen partial pressure catheter probes. Neurosurgery 43:108210951998

16

Fandino JStocker RProkop STrentz OImhof HG: Cerebral oxygenation and systemic trauma-related factors determining neurological outcome after brain injury. J Clin Neurosci 7:2262332000

17

Filippi RReisch RMauer DPerneczky A: Brain tissue pO2 related to SjvO2, ICP, and CPP in severe brain injury. Neurosurg Rev 23:94972000

18

Haitsma IKMaas AI: Advanced monitoring in the intensive care unit: brain tissue oxygen tension. Curr Opin Crit Care 8:1151202002

19

Hong WCTu YKChen YSLien LMHuang SJ: Subdural intracranial pressure monitoring in severe head injury: clinical experience with the Codman MicroSensor. Surg Neurol 66:2 SupplS8S132006

20

Huang SJHong WCHan YYChen YSWen CSTsai YS: Clinical outcome of severe head injury using three different ICP and CPP protocol-driven therapies. J Clin Neurosci 13:8188222006

21

Jaeger MSoehle MSchuhmann MUWinkler DMeixensberger J: Correlation of continuously monitored regional cerebral blood flow and brain tissue oxygen. Acta Neurochir (Wien) 147:51562005

22

Johnston AJSteiner LAColes JPChatfield DAFryer TDSmielewski P: Effect of cerebral perfusion pressure augmentation on regional oxygenation and metabolism after head injury. Crit Care Med 33:1891952005

23

Kiening KLHartl RUnterberg AWSchneider GHBardt TLanksch WR: Brain tissue pO2-monitoring in comatose patients: implications for therapy. Neurol Res 19:2332401997

24

Kiening KLSchneider GHBardt TFUnterberg AWLanksch WR: Bifrontal measurements of brain tissue-PO2 in comatose patients. Acta Neurochir Suppl 71:1721731998

25

Kiening KLUnterberg AWBardt TFSchneider GHLanksch WR: Monitoring of cerebral oxygenation in patients with severe head injuries: brain tissue PO2 versus jugular vein oxygen saturation. J Neurosurg 85:7517571996

26

Lane PLSkoretz TGDoig GGirotti MJ: Intracranial pressure monitoring and outcomes after traumatic brain injury. Can J Surg 43:4424482000

27

Manley GKnudson MMMorabito DDamron SErickson VPitts L: Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg 136:111811232001

28

Manley GTHemphill JCMorabito DDerugin NErickson VPitts LH: Cerebral oxygenation during hemorrhagic shock: perils of hyperventilation and the therapeutic potential of hypoventilation. J Trauma 48:102510322000

29

Marshall LFEisenberg HM: ICP monitoring in severe head injury. J Neurosurg 67:9529531987

30

Marshall LFEisenberg HMJane JALuerssen TGMarmarou AFoulkes MA: The outcome of severe closed head injury. J Neurosurg 75:SupplS28S361991

31

Marshall LFMaas AIMarshall SBBricolo AFearnside MIannotti F: A multicenter trial on the efficacy of using tirilazad mesylate in cases of head injury. J Neurosurg 89:5195251998

32

Marshall LFMarshall SBKlauber MRVan Berkum Clark MEisenberg HJane JA: The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 9:1 SupplS287S2921992

33

Marshall LFSmith RWShapiro HM: The outcome with aggressive treatment in severe head injuries. Part I: the significance of intracranial pressure monitoring. J Neurosurg 50:20251979

34

Marshall LFSmith RWShapiro 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 50:26301979

35

McDonagh MHelfand MCarson SRussman BS: Hyperbaric oxygen therapy for traumatic brain injury: a systematic review of the evidence. Arch Phys Med Rehabil 85:119812042004

36

Menzel MDoppenberg EMZauner ASoukup JReinert MMBullock R: Increased inspired oxygen concentration as a factor in improved brain tissue oxygenation and tissue lactate levels after severe human head injury. J Neurosurg 91:1101999

37

Miller JDButterworth JFGudeman SKFaulkner JEChoi SCSelhorst JB: Further experience in the management of severe head injury. J Neurosurg 54:2892991981

38

Narotam PKBurjonrappa SCRaynor SCRao MTaylon C: Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome. J Pediatr Surg 41:5055132006

39

Narotam PKPuri VRoberts JMTaylon CVora YNathoo N: Management of hypertensive emergencies in acute brain disease: evaluation of the treatment effects of intravenous nicardipine on cerebral oxygenation. J Neurosurg 109:106510742008

40

Neugebauer ELefering RNoth J: New perspectives in neurotrauma research. Restor Neurol Neurosci 14:83841999

41

Ng ILew TWYeo TTSeow WTTan KKOng PL: Outcome of patients with traumatic brain injury managed on a standardised head injury protocol. Ann Acad Med Singapore 27:3323391998

42

Overgaard JTweed WA: Cerebral circulation after head injury. Part 4: Functional anatomy and boundary-zone flow deprivation in the first week of traumatic coma. J Neurosurg 59:4394461983

43

Palmer SBader MKQureshi APalmer JShaver TBorzatta M: The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. American Associations for Neurologic Surgeons. J Trauma 50:6576642001

44

Patel HCBouamra OWoodford MKing ATYates DWLecky FE: Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Lancet 366:153815442005

45

Reinert MBarth ARothen HUSchaller BTakala JSeiler 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) 145:3413502003

46

Rondina CVidetta WPetroni GLujan SSchoon PMori LB: Mortality and morbidity from moderate to severe traumatic brain injury in Argentina. J Head Trauma Rehabil 20:3683762005

47

Sahuquillo JAmoros SSantos APoca MAPanzardo HDominguez L: Does an increase in cerebral perfusion pressure always mean a better oxygenated brain? A study in head-injured patients. Acta Neurochir Suppl 76:4574622000

48

Sarrafzadeh ASKiening KLBardt TFSchneider GHUnterberg AWLanksch WR: Cerebral oxygenation in contusioned vs. nonlesioned brain tissue: monitoring of PtiO2 with Licox and Paratrend. Acta Neurochir Suppl 71:1861891998

49

Sarrafzadeh ASKiening KLCallsen TAUnterberg AW: Metabolic changes during impending and manifest cerebral hypoxia in traumatic brain injury. Br J Neurosurg 17:3403462003

50

Sarrafzadeh ASPeltonen EEKaisers UKuchler ILanksch WRUnterberg AW: Secondary insults in severe head injury—do multiply injured patients do worse?. Crit Care Med 29:111611232001

51

Schneider GHSarrafzadeh ASKiening KLBardt TFUnterberg AWLanksch WR: Influence of hyperventilation on brain tissue-PO2, PCO2, and pH in patients with intracranial hypertension. Acta Neurochir Suppl 71:62651998

52

Signorini DFAlderson P: Therapeutic hypothermia for head injury. Cochrane Database Syst Rev 2:CD0010482000

53

Stiefel MFSpiotta AGracias VHGaruffe AMGuillamondegui OMaloney-Wilensky E: Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring. J Neurosurg 103:8058112005

54

Stiefel MFUdoetuk JDSpiotta AMGracias VHGoldberg AMaloney-Wilensky E: Conventional neurocritical care and cerebral oxygenation after traumatic brain injury. J Neurosurg 105:5685752006

55

Stocchetti NChieregato ADe Marchi MCroci MBenti RGrimoldi N: High cerebral perfusion pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions. Acta Neurochir Suppl 71:1621651998

56

Stocchetti NPenny KIDearden MBraakman RCohadon FIannotti F: Intensive care management of head-injured patients in Europe: a survey from the European Brain Injury Consortium. Intensive Care Med 27:4004062001

57

Teasdale GJennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81841974

58

Valadka ABGopinath SPContant CFUzura MRobertson CS: Relationship of brain tissue PO2 to outcome after severe head injury. Crit Care Med 26:157615811998

59

van den Brink WAvan Santbrink HAvezaat CJHogesteeger CJansen WKloos LM: Monitoring brain oxygen tension in severe head injury: the Rotterdam experience. Acta Neurochir Suppl 71:1901941998

60

van den Brink WAvan Santbrink HSteyerberg EWAvezaat CJSuazo JAHogesteeger C: Brain oxygen tension in severe head injury. Neurosurgery 46:8688762000

61

van Santbrink HMaas AIAvezaat CJ: Continuous monitoring of partial pressure of brain tissue oxygen in patients with severe head injury. Neurosurgery 38:21311996

62

van Santbrink HSchouten JWSteyerberg EWAvezaat CJMaas AI: Serial transcranial Doppler measurements in traumatic brain injury with special focus on the early posttraumatic period. Acta Neurochir (Wien) 144:114111492002

63

van Santbrink Hvan den Brink WASteyerberg EWCarmona Suazo JAAvezaat CJMaas AI: Brain tissue oxygen response in severe traumatic brain injury. Acta Neurochir (Wien) 145:4294382003

64

Visvanathan R: Severe head injury management in a general surgical department. Aust N Z J Surg 64:5275291994

65

Vukic MNegovetic LKovac DGhajar JGlavic ZGopcevic A: The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome. Acta Neurochir (Wien) 141:120312081999

66

Yang XYang SWang MGao Y: Prospective survey on neurosurgical intensive care for patients with severe head injury. Chin J Traumatol 4:93962001

67

Zhi DSZhang SZhou LG: Continuous monitoring of brain tissue oxygen pressure in patients with severe head injury during moderate hypothermia. Surg Neurol 52:3933961999

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 19 19 17
Full Text Views 209 209 66
PDF Downloads 106 106 31
EPUB Downloads 0 0 0

PubMed

Google Scholar