Dias Celeste, Silva Maria João, Pereira Eduarda, Monteiro Elisabete, Maia Isabel, Barbosa Silvina, Silva Sofia, Honrado Teresa, Cerejo António, Aries Marcel J H, Smielewski Peter, Paiva José-Artur, Czosnyka Marek
Neurocritical Care Unit, Intensive Care Department, Hospital Sao Joao, Porto, Portugal,
Neurocrit Care. 2015 Aug;23(1):92-102. doi: 10.1007/s12028-014-0103-8.
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.
To assess staff compliance and outcome impact of a new method of autoregulation-guided treatment (CPPopt) based on continuous evaluation of cerebrovascular reactivity (PRx).
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).
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).
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.
指南推荐急性创伤性脑损伤（TBI）管理中脑灌注压（CPP）值为50 - 70 mmHg，颅内压低于20 mmHg。然而，由于患者具有不同的灌注阈值，适当的个体目标仍未得到充分解决。床边脑自动调节评估可能有助于优化个体CPP指导的治疗。
评估基于脑血管反应性（PRx）持续评估的自动调节指导治疗新方法（CPPopt）的工作人员依从性和结局影响。
在单一神经重症监护病房（NCCU）对接受持续多模态脑监测的重度TBI成年患者进行前瞻性试点研究。根据前4小时窗口，每分钟自动估计CPPopt，作为PRx最低的CPP，表明最佳脑血管压力反应性。尽可能根据CPPopt目标管理患者，否则按照一般/国际指南管理CPP。此外，使用脑血氧饱和度（COx-CPPopt）、脑组织氧合（ORxs-CPPopt）和脑血流量（CBFx-CPPopt）计算其他离线CPPopt估计值。
纳入18例患者，多模态脑监测总时长为5520小时。在整个监测期间，11例患者（6l%）的CPPopt呈U形曲线，5例患者（28%）呈上升或下降曲线，仅2例患者（11%）无拟合曲线。实际CPP与计算的CPPopt显著相关（r = 0.83，p < 0.0001）。入院时保留的自动调节与更高的格拉斯哥昏迷评分相关（p = 0.01）和更好的结局相关（p = 0.01）。我们证明，实际CPP与CPPopt之间差异较大（>10 mmHg）的患者更可能有不良结局（p = 0.04）。CPPopt与其他估计值之间的比较显示了相似的精度限制。使用COx-CPPopt（近红外光谱）获得的偏差最低（-0.1 mmHg）。
使用脑血管压力反应性在床边进行针对性的个体CPP管理似乎是可行的。与CPPopt的大偏差似乎与不良结局相关。使用无创CO（近红外光谱）的COx-CPPopt方法值得进一步评估。
