TY - JOUR
T1 - Clinical and Physiological Events That Contribute to the Success Rate of Finding "Optimal" Cerebral Perfusion Pressure in Severe Brain Trauma Patients
AU - Weersink, Corien S. A.
AU - Aries, Marcel J. H.
AU - Dias, Celeste
AU - Liu, Mary X.
AU - Kolias, Angelos G.
AU - Donnelly, Joseph
AU - Czosnyka, Marek
AU - van Dijk, J. Marc C.
AU - Regtien, Joost
AU - Menon, David K.
AU - Hutchinson, Peter J.
AU - Smielewski, Peter
PY - 2015/9
Y1 - 2015/9
N2 - Objective: Recently, a concept of an individually targeted level of cerebral perfusion pressure that aims to restore impaired cerebral vasoreactivity has been advocated after traumatic brain injury. The relationship between cerebral perfusion pressure and pressure reactivity index normally is supposed to have a U-shape with its minimum interpreted as the value of "optimal" cerebral perfusion pressure. The aim of this study is to investigate the relation between the absence of the optimal cerebral perfusion pressure curve and physiological variables, clinical factors, and interventions.Design: Retrospective analysis of prospectively collected data.Setting: Neurocritical care units in two university centers.Patients: Between May 2012 and December 2013, a total of 48 traumatic brain injury patients were studied with real-time annotation of predefined clinical events. Interventions: None.Measurements and Main Results: All patients had continuous monitoring of arterial blood pressure, intracranial pressure, and cerebral perfusion pressure, with real-time calculations of pressure reactivity index and optimal cerebral perfusion pressure using ICM+ software (Cambridge Enterprise, University of Cambridge, Cambridge, UK). Selected clinical events were inserted on a daily basis, including changes in physiological variables, sedativeanalgesic drugs, vasoactive drugs, and medical/surgical therapies for intracranial hypertension. The collected data were divided into 4-hour periods, with the primary outcome being absence of the optimal cerebral perfusion pressure curve. For every period, mean values (+/- sds) of arterial blood pressure, intracranial pressure, pressure reactivity index, and other physiological variables were calculated; clinical events were organized using predefined scales. In 28% of all 1,561 periods, an optimal cerebral perfusion pressure curve was absent. A generalized linear mixed model with binary logistic regression was fitted. Absence of slow arterial blood pressure waves (odds ratio, 2.7; p <0.001), higher pressure reactivity index values (odds ratio, 2.9; p <0.001), lower amount of sedative-analgesic drugs (odds ratio, 1.9; p = 0.03), higher vasoactive medication dose (odds ratio, 3.2; p = 0.02), no administration of maintenance neuromuscular blockers (odds ratio, 1.7; p <0.01), and following decompressive craniectomy (odds ratio, 1.8; p <0.01) were independently associated with optimal cerebral perfusion pressure curve absence.Conclusions: This study identified six factors that were independently associated with absence of optimal cerebral perfusion pressure curves.
AB - Objective: Recently, a concept of an individually targeted level of cerebral perfusion pressure that aims to restore impaired cerebral vasoreactivity has been advocated after traumatic brain injury. The relationship between cerebral perfusion pressure and pressure reactivity index normally is supposed to have a U-shape with its minimum interpreted as the value of "optimal" cerebral perfusion pressure. The aim of this study is to investigate the relation between the absence of the optimal cerebral perfusion pressure curve and physiological variables, clinical factors, and interventions.Design: Retrospective analysis of prospectively collected data.Setting: Neurocritical care units in two university centers.Patients: Between May 2012 and December 2013, a total of 48 traumatic brain injury patients were studied with real-time annotation of predefined clinical events. Interventions: None.Measurements and Main Results: All patients had continuous monitoring of arterial blood pressure, intracranial pressure, and cerebral perfusion pressure, with real-time calculations of pressure reactivity index and optimal cerebral perfusion pressure using ICM+ software (Cambridge Enterprise, University of Cambridge, Cambridge, UK). Selected clinical events were inserted on a daily basis, including changes in physiological variables, sedativeanalgesic drugs, vasoactive drugs, and medical/surgical therapies for intracranial hypertension. The collected data were divided into 4-hour periods, with the primary outcome being absence of the optimal cerebral perfusion pressure curve. For every period, mean values (+/- sds) of arterial blood pressure, intracranial pressure, pressure reactivity index, and other physiological variables were calculated; clinical events were organized using predefined scales. In 28% of all 1,561 periods, an optimal cerebral perfusion pressure curve was absent. A generalized linear mixed model with binary logistic regression was fitted. Absence of slow arterial blood pressure waves (odds ratio, 2.7; p <0.001), higher pressure reactivity index values (odds ratio, 2.9; p <0.001), lower amount of sedative-analgesic drugs (odds ratio, 1.9; p = 0.03), higher vasoactive medication dose (odds ratio, 3.2; p = 0.02), no administration of maintenance neuromuscular blockers (odds ratio, 1.7; p <0.01), and following decompressive craniectomy (odds ratio, 1.8; p <0.01) were independently associated with optimal cerebral perfusion pressure curve absence.Conclusions: This study identified six factors that were independently associated with absence of optimal cerebral perfusion pressure curves.
KW - Adult
KW - Analgesics
KW - Brain
KW - Brain Injuries
KW - Cardiovascular Agents
KW - Cerebrovascular Circulation
KW - Female
KW - Glasgow Coma Scale
KW - Humans
KW - Hypnotics and Sedatives
KW - Intracranial Hypertension
KW - Intracranial Pressure
KW - Male
KW - Middle Aged
KW - Retrospective Studies
U2 - 10.1097/CCM.0000000000001165
DO - 10.1097/CCM.0000000000001165
M3 - Article
C2 - 26154931
SN - 0090-3493
VL - 43
SP - 1952
EP - 1963
JO - Critical Care Medicine
JF - Critical Care Medicine
IS - 9
ER -