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Svedung Wettervik T, Beqiri E, Hånell A, Bögli SY, Placek M, Donnelly J, Guilfoyle MR, Helmy A, Lavinio A, Hutchinson PJ, Smielewski P. Visualization of Cerebral Pressure Autoregulatory Insults in Traumatic Brain Injury. Crit Care Med 2024; 52:1228-1238. [PMID: 38587420 DOI: 10.1097/ccm.0000000000006287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
OBJECTIVES The first aim was to investigate the combined effect of insult intensity and duration of the pressure reactivity index (PRx) and deviation from the autoregulatory cerebral perfusion pressure target (∆CPPopt = actual CPP - optimal CPP [CPPopt]) on outcome in traumatic brain injury. The second aim was to determine if PRx influenced the association between intracranial pressure (ICP), CPP, and ∆CPPopt with outcome. DESIGN Observational cohort study. SETTING Neurocritical care unit, Cambridge, United Kingdom. PATIENTS Five hundred fifty-three traumatic brain injury patients with ICP and arterial blood pressure monitoring and 6-month outcome data (Glasgow Outcome Scale [GOS]). INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The insult intensity (mm Hg or PRx coefficient) and duration (minutes) of ICP, PRx, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In these plots, there was a transition from favorable to unfavorable outcome when PRx remained positive for 30 minutes and this was also the case for shorter durations when the intensity was higher. In a similar plot of ∆CPPopt, there was a gradual transition from favorable to unfavorable outcome when ∆CPPopt went below -5 mm Hg for 30-minute episodes of time and for shorter durations for more negative ∆CPPopt. Furthermore, the percentage of monitoring time with certain combinations of PRx with ICP, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In the combined PRx/ICP heatmap, ICP above 20 mm Hg together with PRx above 0 correlated with unfavorable outcome. In a PRx/CPP heatmap, CPP below 70 mm Hg together with PRx above 0.2-0.4 correlated with unfavorable outcome. In the PRx-/∆CPPopt heatmap, ∆CPPopt below 0 together with PRx above 0.2-0.4 correlated with unfavorable outcome. CONCLUSIONS Higher intensities for longer durations of positive PRx and negative ∆CPPopt correlated with worse outcome. Elevated ICP, low CPP, and negative ∆CPPopt were particularly associated with worse outcomes when the cerebral pressure autoregulation was concurrently impaired.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Andrea Lavinio
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Pezzato S, Govindan RB, Bagnasco F, Panagopoulos EM, Robba C, Beqiri E, Smielewski P, Munoz RA, d'Udekem Y, Moscatelli A, du Plessis A. Cerebral autoregulation monitoring using the cerebral oximetry index after neonatal cardiac surgery: A single-center retrospective cohort study. J Thorac Cardiovasc Surg 2024; 168:353-363.e4. [PMID: 38065519 DOI: 10.1016/j.jtcvs.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 12/03/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To investigate whether cerebral autoregulation is impaired after neonatal cardiac surgery and whether changes in autoregulation metrics are associated with different congenital heart defects or the incidence of postoperative neurologic events. METHODS This is a retrospective observational study of neonates undergoing monitoring during the first 72 hours after cardiac surgery. Archived data were processed to calculate the cerebral oximetry index (COx) and derived metrics. Acute neurologic events were identified by an electronic medical record review. The Skillings-Mack test and the Wilcoxon signed-rank test were used to analyze the evolution of autoregulation metrics over time; the Mann-Whitney U test was used for comparison between groups. RESULTS We included 28 neonates, 7 (25%) with hypoplastic left heart syndrome and 21 (75%) with transposition of the great arteries. Overall, the median percentage of time spent with impaired autoregulation, defined as percentage of time with a COx >0.3, was 31.6% (interquartile range, 21.1%-38.3%). No differences in autoregulation metrics between different cardiac defects subgroups were observed. Seven patients (25%) experienced a postoperative acute neurologic event. Compared to the neonates without an acute neurologic event, those with an acute neurologic event had a higher COx (0.16 vs 0.07; P = .035), a higher percentage of time with a COx >0.3 (39.4% vs 29.2%; P = .017), and a higher percentage of time with a mean arterial pressure below the lower limit of autoregulation (13.3% vs 6.9%; P = .048). CONCLUSIONS COx monitoring after cardiac surgery allowed for the detection of impaired cerebral autoregulation, which was more frequent in neonates with postoperative acute neurologic events.
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Affiliation(s)
- Stefano Pezzato
- Neonatal and Pediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy; Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC.
| | | | - Francesca Bagnasco
- Epidemiology and Biostatistics Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Chiara Robba
- Anesthesia and Critical Care, IRCCS Policlinico San Martino, Genova, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ricardo A Munoz
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Yves d'Udekem
- Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Adre du Plessis
- Prenatal Pediatrics Institute, Children's National Hospital, Washington, DC
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Kartal A, Robba C, Helmy A, Wolf S, Aries MJH. How to Define and Meet Blood Pressure Targets After Traumatic Brain Injury: A Narrative Review. Neurocrit Care 2024:10.1007/s12028-024-02048-5. [PMID: 38982005 DOI: 10.1007/s12028-024-02048-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings. METHODS We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions. RESULTS Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury. DISCUSSION Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI. CONCLUSIONS We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials.
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Affiliation(s)
- Ahmet Kartal
- University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany.
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel J H Aries
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
- Institute of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
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Beqiri E, García-Orellana M, Politi A, Zeiler FA, Placek MM, Fàbregas N, Tas J, De Sloovere V, Czosnyka M, Aries M, Valero R, de Riva N, Smielewski P. Cerebral autoregulation derived blood pressure targets in elective neurosurgery. J Clin Monit Comput 2024; 38:649-662. [PMID: 38238636 PMCID: PMC11164832 DOI: 10.1007/s10877-023-01115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/23/2023] [Indexed: 06/11/2024]
Abstract
Poor postoperative outcomes may be associated with cerebral ischaemia or hyperaemia, caused by episodes of arterial blood pressure (ABP) being outside the range of cerebral autoregulation (CA). Monitoring CA using COx (correlation between slow changes in mean ABP and regional cerebral O2 saturation-rSO2) could allow to individualise the management of ABP to preserve CA. We aimed to explore a continuous automated assessment of ABPOPT (ABP where CA is best preserved) and ABP at the lower limit of autoregulation (LLA) in elective neurosurgery patients. Retrospective analysis of prospectively collected data of 85 patients [median age 60 (IQR 51-68)] undergoing elective neurosurgery. ABPBASELINE was the mean of 3 pre-operative non-invasive measurements. ABP and rSO2 waveforms were processed to estimate COx-derived ABPOPT and LLA trend-lines. We assessed: availability (number of patients where ABPOPT/LLA were available); time required to achieve first values; differences between ABPOPT/LLA and ABP. ABPOPT and LLA availability was 86 and 89%. Median (IQR) time to achieve the first value was 97 (80-155) and 93 (78-122) min for ABPOPT and LLA respectively. Median ABPOPT [75 (69-84)] was lower than ABPBASELINE [90 (84-95)] (p < 0.001, Mann-U test). Patients spent 72 (56-86) % of recorded time with ABP above or below ABPOPT ± 5 mmHg. ABPOPT and ABP time trends and variability were not related to each other within patients. 37.6% of patients had at least 1 hypotensive insult (ABP < LLA) during the monitoring time. It seems possible to assess individualised automated ABP targets during elective neurosurgery.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Marta García-Orellana
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria
| | - Anna Politi
- Department of Anesthesiology, Intensive Care and Pain Medicine, Milano Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Univesity of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Neus Fàbregas
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Veerle De Sloovere
- Department of Anesthesiology, University Hospitals Leuven, Louvain, Belgium
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Ricard Valero
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Smielewski P, Beqiri E, Mataczynski C, Placek M, Kazimierska A, Hutchinson P, Czosnyka M, Kasprowicz M. Advanced neuromonitoring powered by ICM+ and its place in the Brand New AI World, reflections at the 20th anniversary boundary. BRAIN & SPINE 2024; 4:102835. [PMID: 39071453 PMCID: PMC11278591 DOI: 10.1016/j.bas.2024.102835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 05/06/2024] [Accepted: 05/17/2024] [Indexed: 07/30/2024]
Abstract
Introduction Adoption of the ICM+® brain monitoring software by clinical research centres worldwide has been continuously growing over the past 20 years. This has necessitated ongoing updates to accommodate evolving neuromonitoring research needs, including recent explosion of artificial intelligence (AI). Research question We sought to provide an update on the current features of the software. In particular, we aimed to highlight the new options of integrating AI models. Material and methods We reviewed all currently available ICM+ analytical areas and discussed potential AI based extensions in each. We tested a proof-of-concept integration of an AI model and evaluated its performance for real-time data processing. Results ICM+ current analytical tools serve both real-time (bed-side) and offline (file based) analysis, including the calculation engine, Signal Calculator, Custom Statistics, Batch tools, ScriptLab and charting. The ICM+ Python plugin engine allows to execute custom Python scripts and take advantage of complex AI frameworks. For the proof-of-concept, we used a neural network convolutional model with 207,000 trainable parameters that classifies morphology of intracranial pressure (ICP) pulse waveform into 5 pulse categories (normal to pathological plus artefactual). When evaluated within ICM+ plugin script on a Windows 10 laptop the classification of a 5 min ICP waveform segment took only 0.19s with a 2.3s of initial, one-off, model loading time required. Conclusions Modernised ICM+ analytical tools, reviewed in this manuscript, include integration of custom AI models allowing them to be shared and run in real-time, facilitating rapid prototyping and validating of new AI ideas at the bed-side.
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Affiliation(s)
- P. Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - E. Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - C. Mataczynski
- Department of Computer Engineering, Faculty of Information and Communication Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - A. Kazimierska
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - P.J. Hutchinson
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Computer Engineering, Faculty of Information and Communication Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
- Neurosurgery Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M. Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - M. Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
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Beqiri E. CPPopt on Medical Devices: The Imitation Game. Neurocrit Care 2024:10.1007/s12028-024-01977-5. [PMID: 38570411 DOI: 10.1007/s12028-024-01977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/07/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Erta Beqiri
- Division of Neurosurgery, Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
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Plourde G, Carrier FM, Bijlenga P, Quintard H. Variations in Autoregulation-Based Optimal Cerebral Perfusion Pressure Determination Using Two Integrated Neuromonitoring Platforms in a Trauma Patient. Neurocrit Care 2024:10.1007/s12028-024-01949-9. [PMID: 38424323 DOI: 10.1007/s12028-024-01949-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Neuromonitoring devices are often used in traumatic brain injury. The objective of this report is to raise awareness concerning variations in optimal cerebral perfusion pressure (CPPopt) determination using exploratory information provided by two neuromonitoring monitors that are part of research programs (Moberg CNS Monitor and RAUMED NeuroSmart LogO). METHODS We connected both monitors simultaneously to a parenchymal intracranial pressure catheter and recorded the pressure reactivity index (PRx) and the derived CPPopt estimates for a patient with a severe traumatic brain injury. These estimates were available at the bedside and were updated at each minute. RESULTS Using the Bland and Altman method, we found a mean variation of - 3.8 (95% confidence internal from - 8.5 to 0.9) mm Hg between the CPPopt estimates provided by the two monitors (limits of agreement from - 26.6 to 19.1 mm Hg). The PRx and CPPopt trends provided by the two monitors were similar over time, but CPPopt trends differed when PRx values were around zero. Also, almost half of the CPPopt estimates differed by more than 10 mm Hg. CONCLUSIONS These wide variations recorded in the same patient are worrisome and reiterate the importance of understanding and standardizing the methodology and algorithms behind commercial neuromonitoring devices prior to incorporating them in clinical use.
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Affiliation(s)
- Guillaume Plourde
- Division of Intensive Care Medicine, Department of Medicine, Centre Hospitalier de l'Université de Montréal, 1051 Rue Sanguinet, Montreal, Canada.
| | - François Martin Carrier
- Division of Intensive Care Medicine, Department of Medicine and Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Philippe Bijlenga
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospital, Geneva, Switzerland
| | - Hervé Quintard
- Division of Intensive Care Medicine, Department of Anesthesiology, Clinical Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospital, Geneva, Switzerland
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Beqiri E, Donnelly J, Aries M, Ercole A, Smielewski P. Continuous monitoring of the lower limit of reactivity in traumatic brain injury patients: understanding what is feasible. Crit Care 2023; 27:488. [PMID: 38082313 PMCID: PMC10714627 DOI: 10.1186/s13054-023-04773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Marcel Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Svedung Wettervik T, Beqiri E, Hånell A, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury-part II: isolated and combined insults in relation to outcome. Crit Care 2023; 27:370. [PMID: 37752602 PMCID: PMC10523606 DOI: 10.1186/s13054-023-04659-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The primary aim was to explore the concept of isolated and combined threshold-insults for brain tissue oxygenation (pbtO2) in relation to outcome in traumatic brain injury (TBI). METHODS A total of 239 TBI patients with data on clinical outcome (GOS) and intracranial pressure (ICP) and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Outcome was dichotomised into favourable/unfavourable (GOS 4-5/1-3) and survival/mortality (GOS 2-5/1). PbtO2 was studied over the entire monitoring period. Thresholds were analysed in relation to outcome based on median and mean values, percentage of time and dose per hour below critical values and visualised as the combined insult intensity and duration. RESULTS Median pbtO2 was slightly, but not significantly, associated with outcome. A pbtO2 threshold at 25 and 20 mmHg, respectively, yielded the highest x2 when dichotomised for favourable/unfavourable outcome and mortality/survival in chi-square analyses. A higher dose and higher percentage of time spent with pbtO2 below 25 mmHg as well as lower thresholds were associated with unfavourable outcome, but not mortality. In a combined insult intensity and duration analysis, there was a transition from favourable towards unfavourable outcome when pbtO2 went below 25-30 mmHg for 30 min and similar transitions occurred for shorter durations when the intensity was higher. Although these insults were rare, pbtO2 under 15 mmHg was more strongly associated with unfavourable outcome if, concurrently, ICP was above 20 mmHg, cerebral perfusion pressure below 60 mmHg, or pressure reactivity index above 0.30 than if these variables were not deranged. In a multiple logistic regression, a higher percentage of monitoring time with pbtO2 < 15 mmHg was associated with a higher rate of unfavourable outcome. CONCLUSIONS Low pbtO2, under 25 mmHg and particularly below 15 mmHg, for longer durations and in combination with disturbances in global cerebral physiological variables were associated with poor outcome and may indicate detrimental ischaemic hypoxia. Prospective trials are needed to determine if pbtO2-directed therapy is beneficial, at what individualised pbtO2 threshold therapies are warranted, and how this may depend on the presence/absence of concurrent cerebral physiological disturbances.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
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Cucciolini G, Motroni V, Czosnyka M. Intracranial pressure for clinicians: it is not just a number. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:31. [PMID: 37670387 PMCID: PMC10481563 DOI: 10.1186/s44158-023-00115-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Invasive intracranial pressure (ICP) monitoring is a standard practice in severe brain injury cases, where it allows to derive cerebral perfusion pressure (CPP); ICP-tracing can also provide additional information about intracranial dynamics, forecast episodes of intracranial hypertension and set targets for a tailored therapy to prevent secondary brain injury. Nevertheless, controversies about the advantages of an ICP clinical management are still debated. FINDINGS This article reviews recent research on ICP to improve the understanding of the topic and uncover the hidden information in this signal that may be useful in clinical practice. Parameters derived from time-domain as well as frequency domain analysis include compensatory reserve, autoregulation estimation, pulse waveform analysis, and behavior of ICP in time. The possibility to predict the outcome and apply a tailored therapy using a personalised perfusion pressure target is also described. CONCLUSIONS ICP is a crucial signal to monitor in severely brain injured patients; a bedside computer can empower standard monitoring giving new metrics that may aid in clinical management, establish a personalized therapy, and help to predict the outcome. Continuous collaboration between engineers and clinicians and application of new technologies to healthcare, is vital to improve the accuracy of current metrics and progress towards better care with individualized dynamic targets.
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Affiliation(s)
- Giada Cucciolini
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.
- Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, University of Cambridge, Cambridge, UK.
| | - Virginia Motroni
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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11
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Svedung Wettervik T, Beqiri E, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury: part I-To what extent does PbtO 2 reflect global cerebral physiology? Crit Care 2023; 27:339. [PMID: 37653526 PMCID: PMC10472704 DOI: 10.1186/s13054-023-04627-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The primary aim was to explore the association of global cerebral physiological variables including intracranial pressure (ICP), cerebrovascular reactivity (PRx), cerebral perfusion pressure (CPP), and deviation from the PRx-based optimal CPP value (∆CPPopt; actual CPP-CPPopt) in relation to brain tissue oxygenation (pbtO2) in traumatic brain injury (TBI). METHODS A total of 425 TBI patients with ICP- and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Generalized additive models (GAMs) and linear mixed effect models were used to explore the association of ICP, PRx, CPP, and CPPopt in relation to pbtO2. PbtO2 < 20 mmHg, ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, and ∆CPPopt < - 5 mmHg were considered as cerebral insults. RESULTS PbtO2 < 20 mmHg occurred in median during 17% of the monitoring time and in less than 5% in combination with ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, or ∆CPPopt < - 5 mmHg. In GAM analyses, pbtO2 remained around 25 mmHg over a large range of ICP ([0;50] mmHg) and PRx [- 1;1], but deteriorated below 20 mmHg for extremely low CPP below 30 mmHg and ∆CPPopt below - 30 mmHg. In linear mixed effect models, ICP, CPP, PRx, and ∆CPPopt were significantly associated with pbtO2, but the fixed effects could only explain a very small extent of the pbtO2 variation. CONCLUSIONS PbtO2 below 20 mmHg was relatively frequent and often occurred in the absence of disturbances in ICP, PRx, CPP, and ∆CPPopt. There were significant, but weak associations between the global cerebral physiological variables and pbtO2, suggesting that hypoxic pbtO2 is often a complex and independent pathophysiological event. Thus, other variables may be more crucial to explain pbtO2 and, likewise, pbtO2 may not be a suitable outcome measure to determine whether global cerebral blood flow optimization such as CPPopt therapy is successful.
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Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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12
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Beqiri E, Zeiler FA, Ercole A, Placek MM, Tas J, Donnelly J, Aries MJH, Hutchinson PJ, Menon D, Stocchetti N, Czosnyka M, Smielewski P. The lower limit of reactivity as a potential individualised cerebral perfusion pressure target in traumatic brain injury: a CENTER-TBI high-resolution sub-study analysis. Crit Care 2023; 27:194. [PMID: 37210526 PMCID: PMC10199598 DOI: 10.1186/s13054-023-04485-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND A previous retrospective single-centre study suggested that the percentage of time spent with cerebral perfusion pressure (CPP) below the individual lower limit of reactivity (LLR) is associated with mortality in traumatic brain injury (TBI) patients. We aim to validate this in a large multicentre cohort. METHODS Recordings from 171 TBI patients from the high-resolution cohort of the CENTER-TBI study were processed with ICM+ software. We derived LLR as a time trend of CPP at a level for which the pressure reactivity index (PRx) indicates impaired cerebrovascular reactivity with low CPP. The relationship with mortality was assessed with Mann-U test (first 7-day period), Kruskal-Wallis (daily analysis for 7 days), univariate and multivariate logistic regression models. AUCs (CI 95%) were calculated and compared using DeLong's test. RESULTS Average LLR over the first 7 days was above 60 mmHg in 48% of patients. %time with CPP < LLR could predict mortality (AUC 0.73, p = < 0.001). This association becomes significant starting from the third day post injury. The relationship was maintained when correcting for IMPACT covariates or for high ICP. CONCLUSIONS Using a multicentre cohort, we confirmed that CPP below LLR was associated with mortality during the first seven days post injury.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Frederick A Zeiler
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Marcel J H Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK
| | - David Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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