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Optimal Cerebral Perfusion Pressure Management at Bedside: A Single-Center Pilot Study

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Abstract

Background

Guidelines recommend cerebral perfusion pressure (CPP) values of 50–70 mmHg and intracranial pressure lower than 20 mmHg for the management of acute traumatic brain injury (TBI). However, adequate individual targets are still poorly addressed, since patients have different perfusion thresholds. Bedside assessment of cerebral autoregulation may help to optimize individual CPP-guided treatment.

Objective

To assess staff compliance and outcome impact of a new method of autoregulation-guided treatment (CPPopt) based on continuous evaluation of cerebrovascular reactivity (PRx).

Methods

Prospective pilot study of severe TBI adult patients managed with continuous multimodal brain monitoring in a single Neurocritical Care Unit (NCCU). Every minute CPPopt was automatically estimated, based on the previous 4-h window, as the CPP with the lowest PRx indicating the best cerebrovascular pressure reactivity. Patients were managed with CPPopt targets whenever possible and otherwise CPP was managed following general/international guidelines. In addition, other offline CPPopt estimates were calculated using cerebral oximetry (COx-CPPopt), brain tissue oxygenation (ORxs-CPPopt), and cerebral blood flow (CBFx-CPPopt).

Results

Eighteen patients with a total multimodal brain monitoring time of 5,520 h were enrolled. During the total monitoring period, 11 patients (61 %) had a CPPopt U-shaped curve, 5 patients (28 %) had either ascending or descending curves, and only 2 patients (11 %) had no fitted curve. Real CPP correlated significantly with calculated CPPopt (r = 0.83, p < 0.0001). Preserved autoregulation was associated with greater Glasgow coma score on admission (p = 0.01) and better outcome (p = 0.01). We demonstrated that patients with the larger discrepancy (>10 mm Hg) between real CPP and CPPopt more likely have had adverse outcome (p = 0.04). Comparison between CPPopt and the other estimates revealed similar limits of precision. The lowest bias (−0.1 mmHg) was obtained with COx-CPPopt (NIRS).

Conclusion

Targeted individual CPP management at the bedside using cerebrovascular pressure reactivity seems feasible. Large deviation from CPPopt seems to be associated with adverse outcome. The COx-CPPopt methodology using non-invasive CO (NIRS) warrants further evaluation.

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Acknowledgments

Authors would especially like to thank all the NCCU Nursing staff for their motivation in learning the optimal CPP algorithm and for the commitment to its correct application.

Conflict of interest

The software for brain monitoring ICM+ (www.neurosurg.cam.ac.uk/imcplus) is licensed by the University of Cambridge (Cambridge Enterprise). Peter Smielewski and Marek Czosnyka have financial interests in a part of the licensing fee. All other authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Neurocritical Care Unit, Intensive Care Department, Hospital Sao Joao, Porto, Portugal

    Celeste Dias, Eduarda Pereira, Elisabete Monteiro, Isabel Maia, Silvina Barbosa, Sofia Silva, Teresa Honrado & José-Artur Paiva

  2. Diabetes & Nutritional Sciences Division, King’s College, London, UK

    Maria João Silva

  3. Neurosurgery Department, Hospital Sao Joao, Porto, Portugal

    António Cerejo

  4. Intensive Care/Critical Care Unit, Universitair Medisch Centrum, Groningen, The Netherlands

    Marcel J. H. Aries

  5. Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, UK

    Peter Smielewski & Marek Czosnyka

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  1. Celeste Dias
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Corresponding author

Correspondence to Celeste Dias.

Appendix

Appendix

The initial CT-scan Marshall classification distribution was 6 patients with diffuse injury type II, 3 patients with diffuse injury type III, 4 patients with diffuse injury type IV, and 5 patients with non-evacuated lesions. Before NCCU admission, 4 patients were submitted to craniotomy for hematoma drainage, 3 patients needed early decompression, and 3 had non-neurosurgical procedures. During NCCU stay, 1 patient had an extraventricular drainage and 2 more patients went for late decompression due to refractory intracranial hypertension.

NCCU protocol for Traumatic Brain Injury and Intracranial Hypertension Management is presented in Fig. 5.

Fig. 5
figure 5

Neurocritical Care Unit (NCCU) protocol for Traumatic Brain Injury and Intracranial Hypertension Management. Optimal Cerebral Perfusion Pressure (CPPopt) evaluated continuously at bedside with cerebrovascular reactivity index and Intracranial Pressure (ICP) control below 20 mmHg are primary targets. EKG electrocardiogram, SpO 2 pulse oximetry, ETCO 2 endtidal carbon dioxide, ABP arterial blood pressure, CVP central venous pressure, ICP intracranial pressure, ICM+ multimodal brain monitoring software, NIRS cerebral oximetry with near-infrared light, PbtO 2 brain tissue oxygen pressure, TDF-CBF thermal diffusion cerebral blood flow, EEG electroencephalogram, BIS bispectral index, CPP cerebral perfusion pressure, CPPopt optimal CPP, PaO 2 arterial oxygen pressure, PaCO 2 arterial carbon dioxide pressure, Temp temperature, RASS Richmond agitation–sedation scale, BPS behavioral pain scale, Na+ serum sodium, CT computerized tomography, CSF cerebral spinal fluid

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Dias, C., Silva, M.J., Pereira, E. et al. Optimal Cerebral Perfusion Pressure Management at Bedside: A Single-Center Pilot Study. Neurocrit Care 23, 92–102 (2015). https://doi.org/10.1007/s12028-014-0103-8

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