Effect of Continuous Display of Cerebral Perfusion Pressure on Outcomes in Patients With Traumatic Brain Injury

• Background Clinical bedside monitoring systems do not provide prominent displays of data on cerebral perfusion pressure (CPP). Immediate visual feedback would allow more rapid intervention to prevent or minimize suboptimal pressures. • Objective To evaluate the effect of a highly visible CPP display on immediate and long-term functional outcome in patients with traumatic brain injury. • Methods A total of 157 patients with traumatic brain injury at a level 1 trauma center who had invasive arterial blood pressure and intracranial pressure monitoring were randomized to beds with or without an additional, prominent continuous CPP display. Primary end points were scores on the Extended Glasgow Outcome Scale (GOSE) and Functional Status Examination (FSE) 6 months after injury. Secondary end points were GOSE scores at discharge and 3 months after injury and FSE score 3 months after injury. • Results Although GOSE and FSE scores at 6 months were better in the group with the highly visible CPP display, the differences were not significant. Slope of recovery for GOSE and FSE over all follow-up time points did not differ significantly between groups. However, the intervention’s positive effect on odds of survival at hospital discharge was strong and significant. Within a subgroup of more severely injured patients, the intervention group was much less likely than the control group to have CPP deviations. • Conclusions The presence of a highly visible display of CPP was associated with significantly better odds of survival and overall condition at discharge.

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Blood Pressure Variability and Optimal Cerebral Perfusion Pressure—New Therapeutic Targets in Traumatic Brain Injury

Neurosurgery ◽

10.1093/neuros/nyz515 ◽

2019 ◽

Vol 86 (3) ◽

pp. E300-E309 ◽

Cited By ~ 2

Author(s):

Teodor Svedung Wettervik ◽

Timothy Howells ◽

Anders Lewén ◽

Per Enblad

Keyword(s):

Blood Pressure ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Cerebral Perfusion Pressure ◽

Arterial Blood Pressure ◽

Blood Pressure Variability ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Arterial Blood ◽

Optimal Cerebral Perfusion Pressure

Abstract BACKGROUND Optimal cerebral perfusion pressure (CPPopt) is an autoregulatory-oriented target in the neurointensive care (NIC) of patients with traumatic brain injury (TBI), and deviation from CPPopt is associated with poor outcome. We recently found that blood pressure variability (BPV) is associated with deviation from CPPopt. OBJECTIVE To evaluate BPV and other variables related to deviation from CPPopt and to evaluate challenges and strategies for autoregulatory-oriented treatment in TBI. METHODS Data including arterial blood pressure and intracranial pressure (ICP) from 362 TBI patients treated at the NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2016, were retrospectively analyzed day 2 to 5. RESULTS Higher BPV was a strong predictor of both CPP deviation below and above CPPopt after multiple regression analyses. There was no other explanatory variable for CPP deviation above CPPopt, whereas also higher ICP and worse autoregulation (higher pressure reactivity index) were associated with CPP deviation below CPPopt. A higher BPV was, in turn, explained by older age, lower ICP, higher mean arterial blood pressure, and higher slow arterial blood pressure amplitude (0.018-0.067 Hz). CONCLUSION BPV was strongly associated with deviation from CPPopt. High age is a risk factor for high BPV and hence CPP insults. Our treatment protocol is focused on avoiding CPP below 60 mm Hg. It is possible that a more restrictive upper level could generate more stable blood pressure and less deviation from CPPopt.

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Cerebral Perfusion Pressure and Intracranial Pressure in Traumatic Brain Injury

Annual Review of Nursing Research ◽

10.1891/0739-6686.33.111 ◽

2015 ◽

Vol 33 (1) ◽

pp. 111-183 ◽

Cited By ~ 4

Author(s):

Pamela H. Mitchell ◽

Catherine Kirkness ◽

Patricia A. Blissitt

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Cerebral Perfusion Pressure ◽

Nursing Care ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Secondary Brain Injury ◽

Nursing Research ◽

Arterial Blood

Nearly 300,000 children and adults are hospitalized annually with traumatic brain injury (TBI) and monitored for many vital signs, including intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Nurses use these monitored values to infer the risk of secondary brain injury. The purpose of this chapter is to review nursing research on the monitoring of ICP and CPP in TBI. In this context, nursing research is defined as the research conducted by nurse investigators or research about the variables ICP and CPP that pertains to the nursing care of the TBI patient, adult or child. A modified systematic review of the literature indicated that, except for sharp head rotation and prone positioning, there are no body positions or nursing activities that uniformly or nearly uniformly result in clinically relevant ICP increase or decrease. In the smaller number of studies in which CPP is also measured, there are few changes in CPP since arterial blood pressure generally increases along with ICP. Considerable individual variation occurs in controlled studies, suggesting that clinicians need to pay close attention to the cerebrodynamic responses of each patient to any care maneuver. We recommend that future research regarding nursing care and ICP/CPP in TBI patients needs to have a more integrated approach, examining comprehensive care in relation to short- and long-term outcomes and incorporating multimodality monitoring. Intervention trials of care aspects within nursing control, such as the reduction of environmental noise, early mobilization, and reduction of complications of immobility, are all sorely needed.

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Feasibility of individualised severe traumatic brain injury management using an automated assessment of optimal cerebral perfusion pressure: the COGiTATE phase II study protocol

BMJ Open ◽

10.1136/bmjopen-2019-030727 ◽

2019 ◽

Vol 9 (9) ◽

pp. e030727 ◽

Cited By ~ 20

Author(s):

Erta Beqiri ◽

Peter Smielewski ◽

Chiara Robba ◽

Marek Czosnyka ◽

Manuel Teixeira Cabeleira ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Cerebral Perfusion Pressure ◽

Severe Traumatic Brain Injury ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Large Body ◽

Intervention Group ◽

Intensity Level ◽

Brain Trauma Foundation

IntroductionIndividualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines.Methods and analysisCPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intracranial pressure monitoring are randomised within the first 24 hours of admission in neurocritical care unit. For the control arm, the CPP target is the Brain Trauma Foundation guidelines target (60–70 mm Hg); for the intervention group an automated CPP target is provided as the CPP at which the patient’s cerebrovascular reactivity is best preserved (CPPopt). For a maximum of 5 days, attending clinicians review the CPP target 4-hourly. The main hypothesis of COGiTATE are: (1) in the intervention group the percentage of the monitored time with measured CPP within a range of 5 mm Hg above or below CPPopt will reach 36%; (2) the difference in between groups in daily therapy intensity level score will be lower or equal to 3.Ethics and disseminationEthical approval has been obtained for each participating centre. The results will be presented at international scientific conferences and in peer-reviewed journals.Trial registration numberNCT02982122

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