Brain tissue oxygen–directed management and outcome in patients with severe traumatic brain injury

Clinical article

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Object

The object of this study was to determine whether brain tissue oxygen (PbtO2)–based therapy or intracranial pressure (ICP)/cerebral perfusion pressure (CPP)–based therapy is associated with improved patient outcome after severe traumatic brain injury (TBI).

Methods

Seventy patients with severe TBI (postresuscitation GCS score ≤ 8), admitted to a neurosurgical intensive care unit at a university-based Level I trauma center and tertiary care hospital and managed with an ICP and PbtO2 monitor (mean age 40 ± 19 years [SD]) were compared with 53 historical controls who received only an ICP monitor (mean age 43 ± 18 years). Therapy for both patient groups was aimed to maintain ICP < 20 mm Hg and CPP > 60 mm Hg. Patients with PbtO2 monitors also had therapy to maintain PbtO2 > 20 mm Hg.

Results

Data were obtained from 12,148 hours of continuous ICP monitoring and 6,816 hours of continuous PbtO2 monitoring. The mean daily ICP and CPP and the frequency of elevated ICP (> 20 mm Hg) or suboptimal CPP (< 60 mm Hg) episodes were similar in each group. The mortality rate was significantly lower in patients who received PbtO2-directed care (25.7%) than in those who received conventional ICP and CPP–based therapy (45.3%, p < 0.05). Overall, 40% of patients receiving ICP/CPP–guided management and 64.3% of those receiving PbtO2–guided management had a favorable short-term outcome (p = 0.01). Among patients who received PbtO2-directed therapy, mortality was associated with lower mean daily PbtO2 (p < 0.05), longer durations of compromised brain oxygen (PbtO2 < 20 mm Hg, p = 0.013) and brain hypoxia (PbtO2 < 15 mm Hg, p = 0.001), more episodes and a longer cumulative duration of compromised PbtO2 (p < 0.001), and less successful treatment of compromised PbtO2 (p = 0.03).

Conclusions

These results suggest that PbtO2-based therapy, particularly when compromised PbtO2 can be corrected, may be associated with reduced patient mortality and improved patient outcome after severe TBI.

Abbreviations used in this paper: CPP = cerebral perfusion pressure; FiO2 = fraction of inspired oxygen; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; HUP = Hospital of the University of Pennsylvania; ICP = intracranial pressure; ICU = intensive care unit; ISS = Injury Severity Score; LOS = length of stay; PbtO2 = partial pressure of brain tissue O2; SaO2 = arterial O2 saturation; TBI = traumatic brain injury.

Article Information

Address correspondence to: Peter D. Le Roux, M.D., Department of Neurosurgery, University of Pennsylvania, 330 South 9th Street, Philadelphia, Pennsylvania 19107. email: lerouxp@uphs.upenn.edu.

Please include this information when citing this paper: published online April 23, 2010; DOI: 10.3171/2010.1.JNS09506.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Left: Histogram illustrating the mortality rates (%) in patients undergoing traditional ICP/CPP management and PbtO2 management. *p < 0.05. Right: Histogram illustrating short-term outcome (%) for patients undergoing traditional ICP/CPP management or PbtO2 management. A favorable outcome denotes a GOS of good or moderate disability. An unfavorable outcome denotes death, vegetative state, or severe disability. **p = 0.01.

References

1

Alves WMBiostatistical issues in neuroemergency clinical trials. Alves WMSkolnick BE: Handbook of Neuroemergency Clinical Trials AmsterdamAcademic Press2006. 205227

2

American College of Surgeons Committee on Trauma: Advanced Trauma Life Support Course for Doctors ChicagoAmerican College of Surgeons1997

3

Astrup JSørensen PMSørensen HR: Oxygen and glucose consumption related to Na+-K+ transport in canine brain. Stroke 12:7267301981

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

Bergsneider MHovda DAShalmon EKelly DFVespa PMMartin NA: Cerebral hyperglycolysis following severe traumatic brain injury in humans: a positron emission tomography study. J Neurosurg 86:2412511997

6

Birmingham K: Future of neuroprotective drugs in doubt. Nat Med 8:52002

7

Brain Trauma Foundation: Guidelines for the Management and Prognosis of Severe Traumatic Brain Injury New YorkThe Brain Trauma Foundation2000

8

Brain Trauma Foundation: American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, et al: Guidelines for the management of severe traumatic brain injury. J Neurotrauma 24:1 Suppl2007

9

Brain Trauma Foundation: American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, et al: Guidelines for the management of severe traumatic brain injury. X. Brain oxygen monitoring and thresholds. J Neurotrauma 24:1 SupplS65S702007

10

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

11

Clifton GLMiller ERChoi SCLevin HSMcCauley SSmith KR Jr: Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 344:5565632001

12

Contant CFValadka ABGopinath SPHannay HJRobertson CS: Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg 95:5605682001

13

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

14

Edwards PArango MBalica LCottingham REl-Sayed HFarrell B: Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet 365:195719592005

15

Elf KNilsson PRonne-Engström EHowells TEnblad P: Cerebral perfusion pressure between 50 and 60 mm Hg may be beneficial in head-injured patients: a computerized secondary insult monitoring study. Neurosurgery 56:9629712005

16

Enriquez PBullock R: Molecular and cellular mechanisms in the pathophysiology of severe head injury. Curr Pharm Des 10:213121432004

17

Flynn EPAuer RN: Eubaric hyperoxemia and experimental cerebral infarction. Ann Neurol 52:5665722002

18

Gopinath SPRobertson CSContant CFHayes CFeldman ZNarayan RK: Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry 57:7177231994

19

Gracias VHGuillamondegui ODStiefel MFWilensky EMBloom SGupta R: Cerebral cortical oxygenation: a pilot study. J Trauma 56:4694742004

20

Hlatky RValadka ABGoodman JCContant CFRobertson CS: Patterns of energy substrates during ischemia measured in the brain by microdialysis. J Neurotrauma 21:8949062004

21

Jaggi JLObrist WDGennarelli TALangfitt TW: Relationship of early cerebral blood flow and metabolism to outcome in acute head injury. J Neurosurg 72:1761821990

22

Katayama YBecker DPTamura THovda DA: Massive increases in extracellular potassium and the indiscriminate release of glutamate following concussive brain injury. J Neurosurg 73:8899001990

23

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

24

Le Roux PDNewell DWLam AMGrady MSWinn HR: Cerebral arteriovenous oxygen difference: a predictor of cerebral infarction and outcome in patients with severe head injury. J Neurosurg 87:181997

25

Ling GSNeal CJ: Maintaining cerebral perfusion pressure is a worthy clinical goal. Neurocrit Care 2:75812005

26

Maas AIMurray GHenney H IIIKassem NLegrand VMangelus M: Efficacy and safety of dexanabinol in severe traumatic brain injury: results of a phase III randomised, placebo-controlled, clinical trial. Lancet Neurol 5:38452006

27

Marmarou ASignoretti SFatouros PPPortella GAygok GABullock MR: Predominance of cellular edema in traumatic brain swelling in patients with severe head injuries. J Neurosurg 104:7207302006

28

Marshall LF: Head injury: recent past, present, and future. Neurosurgery 47:5465612000

29

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

30

Martin NAPatwardhan RVAlexander MJAfrick CZLee JHShalmon E: Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm. J Neurosurg 87:9191997

31

Mazzeo ATBullock R: Monitoring brain tissue oxymetry: will it change management of critically ill neurologic patients?. J Neurol Sci 261:192007

32

Meixensberger JJaeger MVäth ADings JKunze ERoosen K: Brain tissue oxygen guided treatment supplementing ICP/CPP therapy after traumatic brain injury. J Neurol Neurosurg Psychiatry 74:7607642003

33

Menon DKColes JPGupta AKFryer TDSmielewski PChatfield DA: Diffusion limited oxygen delivery following head injury. Crit Care Med 32:138413902004

34

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

35

Murray GDButcher IMcHugh GSLu JMushkudiani NAMaas AIR: Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:3293372007

36

Narayan RKKishore PRBecker DPWard JDEnas GGGreenberg RP: Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg 56:6506591982

37

Narayan RKMichel MEAnsell BBaethmann ABiegon ABracken MB: Clinical trials in head injury. J Neurotrauma 19:5035572002

38

Nordström CH: Physiological and biochemical principles underlying volume-targeted therapy—the “Lund concept”. Neurocrit Care 2:83952005. (Review)

39

Nortje JGupta AK: The role of tissue oxygen monitoring in patients with acute brain injury. Br J Anaesth 97:951062006

40

Palzur EVlodavsky EMulla HArieli RFeinsod MSoustiel JF: Hyperbaric oxygen therapy for reduction of secondary brain damage in head injury: an animal model of brain contusion. J Neurotrauma 21:41482004

41

Roberts ISchierhout GPAlderson P: Absence of evidence for the effectiveness of five interventions routinely used in the intensive care management of severe head injury: a systematic review. J Neurol Neurosurg Psychiatry 65:7297331998

42

Robertson CCritical care management of traumatic brain injury. Winn HR: Youmans Neurological Surgery ed 5PhiladelphiaSaunders2004. 51035144

43

Robertson CSValadka ABHannay HJContant CFGopinath SPCormio M: Prevention of secondary ischemic insults after severe head injury. Crit Care Med 27:208620951999

44

Sahuquillo JAmoros SSantos APoca MAPanzardo HDomínguez 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

45

Siesjö BKSiesjö P: Mechanisms of secondary brain injury. Eur J Anaesthesiol 13:2472681996

46

Singhal ABBenner TRoccatagliata LKoroshetz WJSchaefer PWLo EH: A pilot study of normobaric oxygen therapy in acute ischemic stroke. Stroke 36:7978022005

47

Singhal ABDijkhuizen RMRosen BRLo EH: Normobaric hyperoxia reduces MRI diffusion abnormalities and infarct size in experimental stroke. Neurology 58:9459522002

48

Smith MJStiefel MFMagge SFrangos SBloom SGracias V: Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med 33:110411082005

49

Stein SCGraham DIChen XHSmith DH: Association between intravascular microthrombosis and cerebral ischemia in traumatic brain injury. Neurosurgery 54:6876912004

50

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

51

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

52

Temkin NRAnderson GDWinn HREllenbogen RGBritz GWSchuster J: Magnesium sulfate for neuroprotection after traumatic brain injury: a randomised controlled trial. Lancet Neurol 6:29382007

53

Tolias CMReinert MSeiler RGilman CScharf ABullock MR: 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 Neurosurg 101:4354442004

54

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

55

van den Brink WAvan Santbrink HAvezaat CJHogesteeger CJansen WKloos LM: Monitoring brain oxygen tension in severe head injury: the Rotterdam experience. Acta Neurochir 71:Suppl1901941998

56

van den Brink WAvan Santbrink HSteyerberg EWAvezaat CJSuazo JAHogesteeger C: Brain oxygen tension in severe head injury. Neurosurgery 46:8688782000

57

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

58

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

59

Vespa PMO'Phelan KMcArthur DMiller CEliseo MHirt D: Pericontusional brain tissue exhibits persistent elevation of lactate/pyruvate ratio independent of cerebral perfusion pressure. Crit Care Med 35:115311602007

60

Wilensky EMBloom SLeichter DVerdiramo AMLedwith MStiefel M: Brain tissue oxygen practice guidelines using the LICOX CMP monitoring system. J Neurosci Nurs 37:2782882005

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