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

Clinical article

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  • 1 Departments of Neurosurgery,
  • 2 Neurology,
  • 3 Anesthesiology and Critical Care;
  • 4 Center for Clinical Epidemiology and Biostatistics; and
  • 5 Division of Trauma Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
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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.

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Contributor Notes

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.

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