Multimodal Monitoring in Head Injured Patients Management of

Multimodal Monitoring in Head Injured Patients Management of CPP: Detection and Treatment of optimal CPP Jürgen Meixensberger Department of Neurosurgery

CPP = index of input pressure determining CBF and perfusion 1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Therapy Effect of reduced CBF ml/100 g/min Ischemia Edema, Lactate Penumbra Loss of electric activity Loss of Na/K Pump, ATP Infarction Cell death

Risk to secondary ischemic brain damage § Traumatic brain injury diffuse focal, multiple § Subarachnoid Hemorrhage Vasospasm § Ischemic Stroke Penumbra

Guideline German Society of Neurosurgery Traumatic Brain Injury in Adults CPP „Adequate cerebral perfusion pressure is necessary to provide a sufficient cerebral blood flow. The question, whether to treat increased ICP or maintainance of CPP as first treatment goal, is still controversial in the literature. “ AWMF – Leitlinien – Register Nr. 008/001

Cerebral Perfusion Pressure CPP Definition Cerebral Perfusion Pressure* is a surrogate of cerebral blood flow CBF = CPP (MAP – ICP*)/CVR * Referenced to the Foramen of Monroi

CPP and Cerebral Oxygenation Induced Hypertension Jaeger M, Acta Neurochir 2005 Valadka A, Acta Neurochir 2002 Menzel M, J Neurosurg Anesthesiol 1999 Doppenberg E, Surg Neurol 1998 Meixensberger J, JNNP 2003 Individual increasing of CPP guided by Pti. O 2 >10 mm. Hg decreased significantly amount of hypoxic episodes after TBI.

1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Causes 6. Therapy CPP=70 mm. Hg CPP=90 mm. Hg Coles JP, Brain 2004

§ The optimal CPP in patients suffering from TBI is unclear. § Recommendations: From CPP>50, > 60 mm. Hg to CPP>90 mm. Hg § Reduced as well as high CPP influenced Outcome in a negative manner. Robertson et al. Crit Care Med 1999, Contant et al. J Neurosurg 2001 (n=189) Balestreri et al. Neurocrit Care 2006 (n=429)

Outcome - Function of ICP and CPP Balestreri et al Neurocritical Care 2006 N = 429

Optimal CPP Brain Trauma Foundation, J Neurotrauma 2003, 2007 CPP < 70 mm. Hg CPP > 60 mm. Hg Avoid CPP < 50 mm. Hg Intact Autoregulation: CPP > 70 mm. Hg Robertson C, Crit Care Med 1999 Robertson et al. , Contant et al. J Neurosurg 2001 (n=189) Balestreri et al. Neurocrit Care 2006 (n=429) EBIC, Acta Neurochir 1997 CPP 60– 70 mm. Hg Meixensberger J, Acta Neurochir 1993

Optimized CPP - Therapy * TBI N = 30 * Episode > 10 min

1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Causes 6. Therapy % % ppti. O 2 < 10 mm. Hg F R E Q U E N C Y Day 1 -2 Day 3 -5 CPP mm. Hg Day 6 -8

1. Why? 2. Critical Border ? 3. Time Course ? 4. Individual optimized CPP ? 5. Causes Effect of reduced CBF ml/100 g/min Ischemia Edema, Lactate Penumbra Loss of electric activity Loss of Na/K Pump, ATP 6. Therapy Infarction Cell death

§ Concept individual optimized CPP (CPPopt) Steiner et al. Crit Care Med 2002 (n=114) § Based on continous monitoring of cerebrovascular pressure reactivity index PRX § PRx = moving correlation coefficient MAP / ICP Czosnyka et al. Neurosurgery 1997

PRx Individual optimized CPPopt CPP Steiner et al. Crit Care Med 2002

PRx Individual optimized CPP + Pti. O 2 CPPopt CPP Steiner et al. Crit Care Med 2002

§ TBI n=33 § Continous Monitoring (ICM-plus Software) MAP ICP [Codman] CPP Pti. O 2 [Licox] § PRx = moving correlationcoefficient MAP / ICP §Czosnyka et al. Neurosurgey 1997 § Data analysis CPP vs. PRx CPP vs. Pti. O 2 CPP-class of 5 mm. Hg

Results: § CPPopt n=28/33 § CPPopt n=7 60 -65 mm. Hg n=1 65 -70 mm. Hg n=8 70 -75 mm. Hg n=1 75 -80 mm. Hg n=6 80 -85 mm. Hg n=3 85 -90 mm. Hg n=2 90 -95 mm. Hg PRx (85 %) CPP

PRx CPPopt CPP

Pti. O 2 PRx CPPopt CPP

PRx CPPopt CPP

Pti. O 2 PRx CPPopt CPP

Pti. O 2 PRx n=28 CPPopt CPP Jaeger et al Crit Care Med 2010

Therapeutic Options: CPP > 60, < 70 mm. Hg * § Induced hypervolemia with cristalloids Cave: heart insufficience § No body/head – elevation 0° § Inotropica – infusion Cave: acute coronary syndrome, arrhythmia § Diuretics – Reduction of centralvenous pressure § Ventilation - „best PEEP“ - concept * Option; Prognostic value only given by case reports;

Management of CPP after TBI Recommendations: Avoid CPP < 50 mm. Hg – to minimize edema formation CPP > 70 – 80 mm. Hg – can improve perfusion if autoregulation is intact Class II evidence CPP of 60 mm. Hg – sufficient CBF and cerebral perfusion in most cases Ancillary monitoring is helpful to target CPP

Management of CPP after TBI Recommendations: Need for more data § Individualized optimal CPP based on hemodynamic monitoring/ pressure autoregulation indices § Randomized outcome studies

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