The Use Of Both Intracranial Pressure And Brain Tissue PO₂Monitors And Goal Directed Brain Tissue PO₂in Severe Traumatic Brain Injury Patients

Traumatic brain injury (TBI) remains the major cause of mortality and morbidity in worldwide.To date, there is no effective drug treatment for TBI. An important goal of neurocritical care isidentifying and managing the secondary brain injury that evolves in the hours and days after TBI.Intracranial pressure (ICP) is the physiological parameter most frequently monitored. ICP monitoringmay be insufficient to detect all episodes of SBI. With the technological developments, PbtO2is likelythe ideal choice in detecting brain hypoxia in neurocritical care patients. The most recent Guidelines forSevere Traumatic Brain Injury include the use of PbtO2monitors but do not provide guidance abouthow PbtO2should be managed and which medical therapies restore normal PbtO2in TBI patients.Furthermore, whether PbtO2-based therapy is associated with improved outcome is unclear.Osmotherapy is frequently used to control elevated ICP. Although mannitol is more frequently usedas a first tier therapy for elevated ICP, some authors have argued that hypertonic saline (HTS) might bea more effective agent. There has been limited study on the effect of different osmotic therapies onPbtO2in brain injured patients.Traumatic brain injury often develop anaemia and may require red blood cell transfusion(RBCT).However, there is little understanding of the effects of transfusion on cerebral oxygenation.There is little understanding of the effects of transfusion on cerebral oxygenation Whether can gainfurther insight into the optimal transfusion strategy in patients with severe TBI needes a prospectiveclinical study.Severe TBI are often accompanied with multiple injuries, especially the thoracic or abdominalinjury, which prone to be hypotension or hypoxia, increasing the risk of secondary injury, worsens theprognosis of the patient. However, few studies have examined the effect of Concomitant Injuries oncerebral oxygenation in patients with severe TBI. As a result, in this study, we divided the content into three parts.Part ⅠThe use of both intracranial pressure and brain tissue PO2monitors and goal directed brain tissue PO2in severe traumatic braininjury patientsObjective To elucidate the effectiveness of brain tissue oxygenation（PbtO2）plusintracranial pressure（ICP）monitoring and targeted therapy in patients of severe traumatic brain injury（TBI）. MethodsAtotal of46patients with severe TB（IGlasgow Coma Scale, GCS scale≤8）admittedat Jiangyin People’s Hospital from June2010to June2012were divided randomly into2groups andevaluated prospectively．Patients undergoing ICP plus PbtO2monitoring were compared with controlswith ICP monitoring alone. Therapies of both patient groups was attempted to maintain an ICP＜20mmHg and a cerebral perfusion pressure (CPP)≥60mm Hg. Among those with PbtO2monitoring,oxygenation was maintained at a level of≥20mm Hg. The scores of Glasgow outcome scale （GOS）were compared between two groups at Month6post-injury.Results The mean daily ICP and CPP levelswere similar in each group.The mortality rate was21.7%in patients with ICP monitoring alone and thefavorable outcome rate was47.8%.However,those receiving combined management had a significantlyreduced mortality rate of8.7%and good outcome rate of65.2%(P<0.05). Two hundred and thirty-sixepisodes of compromised PbtO2were identified from PbtO2monitoring. Medical management used ina“cause-directed”manner successfully reversed65%of the episodes of compromised PbtO2, defined asrestoration of a “normal” PbtO2(≥20mm Hg). Increasing FiO2, sedation, and pressors were the mostfrequent interventions. Successful medical treatment of brain hypoxia was associated with decreasedmortality. Survivors (n=21) had a72%rate of response to treatment and non-survivors (n=2) had a35%rate of response （P＜0.05）. The Glasgow Outcome Scale score at6months in patients treatedwith PbtO2demonstrated patients with good outcome (n=15) had a81%rate of response to treatmentand those with poor outcome (n=8) had a44%rate of response （P＜0.05）. Conclusions Thecombined use of both ICP and PbtO2may be associated with reduced patient mortality and improvedpatient outcome with severe TBI. Medical interventions other than those to treat ICP and CPP canimprove PbtO2. PartⅡ The influence of therapeutics measures（hypertonic saline andpacked red blood cell transfusion）on brain tissue PO2in severe traumaticbrain injury patientsFacor1. Effect of3%hypertonic saline and20%mannitol on cerebraloxygenation inpatients with severe traumatic brain injury and intracranial hypertensionObject To explore if3%hypertonic saline（HTS）and20%mannitol treatment of raisedintracranial pressure（ICP）will result in an improvement in brain tissue PO2(PbtO2) in severe traumaticbrain injury patients. Methods40patients with severe TBI（Glasgow Coma Scale,GCS scale<8）admitted at Jiangyin People’s Hospital NICU from June2010to June2012were divided into twogroups:3%HTS group and20%mannitol group randomly and evaluated prospectively. Step-wisetherapy under ICP monitoring，if ICP＞20mmHg，patients were received osmotic therapies：either3%HTS or20%mannitol according randomized groups at a defined infusion rate, PbtO2, ICP, mean arterialpressure (MAP), cerebral perfusion pressure (CPP), central venous pressure (CVP)，harte rate （HR），were monitored continuously and the time point30min、60min、120min、180min data was recorded.Results Of the40patients,18patients received3%HTS and17received20%mannitol therapy. Infive patients,ICP did not exceed20mm Hg so osmotic treatment was not necessary.3%HTS and20%mannitol were both associated with a significant ICP reduction from30min to180min after the end ofinfusion (p <0.05).The maximum decrease in ICP and increase in CPP occurred in both groups after60min after the end of infusion (p <0.05). Compared with mannitol,3%HTS was associated with lowerICP and higher MAP and CPP from60min to180min after treatment (p <0.05). HTS treatment wasalso associated with an increase in PbtO2，while20%mannitol did not affect PbtO2at all times analysed(p＞0.05). Conclusions3%HTS and20%mannitol are both effective in reducing ICP and increasingCPP in the treatment of increased ICP. Compared with20%mannitol,3%HTS therapy is associatedwith a significant increase in brain oxygenation and with reduced patient mortality and improved patientoutcome with severe TBI. Facor2. The ealy effect of packed red blood cell transfusion on brain tissue oxygenation withsevere traumatic brain injuryObject To examine the ealy effect of packed red blood cell transfusion on cerebraloxygenation in patients with sTBI. Methods18patients with STBI（Glasgow Coma Scale,GCSscale<8） admitted at Jiangyin People’s Hospital NICU from June2010to June2012, which receiving2unit packed red blood cell transfusion (RBCT) when hemoglobin concentration70-90g/L and PbtO2＜20mmHg, were studied prospectively. To analyze the changes of the following physiologic variablesbefore and2hrs after RBCT: PbtO2, intracranial pressure, cerebral perfusion pressure, hemoglobinoxygen saturation (SaO2), FIO2, hemoglobin, and hematocrit. Results Twenty blood transfusions in18patients were evaluated. The mean (SD) increase in PbtO2for all patients was（5.3±2.4mm Hg）(p＜0.05), Improvement in PbtO2was associated with a significant mean increase in hemoglobin afterRBCT（11±6g/L）(p＜0.05). ICP，Cerebral perfusion pressure, SaO2did not change significantlyafter RBCT.65%of (n=13) patients experienced an increase in PbtO2during the course of the study,whereas in35%of patients, PbtO2either did not change or decreased. the multivariant correlation andregression analysis revealed change in hemoglobin concentration to significantly and positivelyassociated with change in PbtO2（partial regression coefficient was0.12，95%confidence interval0.04-0.22，P＜0.05. Conclusions Transfusion of packed red blood cells ealy results in improved braintissue oxygen with sTBI. Part Ⅲ The use of both intracranial pressure and brain tissue PO2monitors and goal directed brain tissue PO2in severe traumatic braininjury patients whith multiple injuriesObject To elucidate the effectiveness of brain tissue PO2combined intracranial pressure （ICP）、mean arterial pressure (MAP)、central venous pressure(CVP）multiple monitors and therapy directed at brain tissue PO2in severe traumatic brain injury whith multiple injuries patients. Methods20isolatedsevere TBI patients（Glasgow Coma Scale,GCS <8）and20severe TBI patients with associatedextracranial injuries（GCS <8，Injury Severity Score，ISS＞16)）admitted at Jiangyin People’s HospitalNICU from June2010to June2012were evaluated prospectively．All the patients treated with braintissue PO2combined intracranial pressure、mean arterial pressure、central venous pressure multiplemonitors. Therapy in both patient groups was aimed at maintaining an ICP less than20mmHg, acerebral perfusion pressure (CPP) greater than60mmHg and oxygenation was maintained at levelsgreater than20mm Hg. The occurrence of secondary brain injuries (ICP>20mm Hg, CPP <60mm Hg,PbtO2<20mm Hg) was comparable in patients with sTBI and those sTBI patients with associatedmultiple injuries. The secondary insults and the scores of Glasgow outcome scale （GOS）were alsocompared between two groups at Month6post-injury. Results The ICP and CPP levels and occurrenceof ICP>20mm Hg, CPP <60mm Hg were similar between the two groups after treated2h，24h，48hand72h（P＞0.05）. The brain tissue PO2levels and occurrence of PbtO2<20mm Hg in sTBI patientswith associated multiple injuries were lower those in isolated severe TBI patients after treated2h，24hand48h（P＜0.05）, however, this difference couldn’t be found after treated72h（P＞0.05）.Themortality rate was35%and the favorable outcome rate was45%in isolated severe TBI patients.Patients with associated multiple injuries had a40%mortality rate and40%good outcome rate （P＞0.05）. Medical management used in a “cause-directed” manner successfully reversed65%of theepisodes of compromised PbtO2in isolated severe TBI patients and78%of episodes of compromisedbrain oxygen were corrected in sTBI patients with associated multiple injuries. Conclusions Thecombined use of brain tissue PO2monitors and multimodality monitoring can detected brainproxia.Therapy directed at brain tissue PO2, is associated with decreased disability rate and mortalityfollowing sTBI patients with associated multiple injuries.