Effects of brain tissue oxygen (PbtO2) guided management on patient outcomes following severe traumatic brain injury: A systematic review and meta-analysis

Hays, Leanne; Udy, Andrew; Adamides, Alexios A.; Anstey, James; Bailey, Michael; Bellapart, Judith; Byrne, Kathleen; Cheng, Andrew; Cooper, David; Drummond, Katharine J.; Hænggi, Matthias; Jakob, Stephan M.; Higgins, Alisa; Lewis, Philip; Hunn, Martin; McNamara, Robert M.; Menon, David; Murray, Lynne; Reddi, Benjamin; Trapani, Tony; Vallance, Shirley; Young, Paul; Shutter, Lori; Murray, Patrick; Curley, Gerard F.; Nichol, Alistair

doi:10.1016/j.jocn.2022.03.017

Cited by 18 publications

(19 citation statements)

References 31 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Interest has shifted towards personalized medicine-based strategies that leverage contemporary multimodal monitoring techniques [4,5]. Two methods that have come to the forefront are brain tissue oxygen tension (PbtO 2 ) and ICP-based cerebrovascular pressure reactivity monitoring [6,7].…”

Section: Introductionmentioning

confidence: 99%

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Gomez

Sekhon

Griesdale

et al. 2022

ICMx

View full text Add to dashboard Cite

Background Brain tissue oxygen tension (PbtO2) and cerebrovascular pressure reactivity monitoring have emerged as potential modalities to individualize care in moderate and severe traumatic brain injury (TBI). The relationship between these modalities has had limited exploration. The aim of this study was to examine the relationship between PbtO2 and cerebral perfusion pressure (CPP) and how this relationship is modified by the state of cerebrovascular pressure reactivity. Methods A retrospective multi-institution cohort study utilizing prospectively collected high-resolution physiologic data from the CAnadian High Resolution-TBI (CAHR-TBI) Research Collaborative database collected between 2011 and 2021 was performed. Included in the study were critically ill TBI patients with intracranial pressure (ICP), arterial blood pressure (ABP), and PbtO2 monitoring treated in any one of three CAHR-TBI affiliated adult intensive care units (ICU). The outcome of interest was how PbtO2 and CPP are related over a cohort of TBI patients and how this relationship is modified by the state of cerebrovascular reactivity, as determined using the pressure reactivity index (PRx). Results A total of 77 patients met the study inclusion criteria with a total of 377,744 min of physiologic data available for the analysis. PbtO2 produced a triphasic curve when plotted against CPP like previous population-based plots of cerebral blood flow (CBF) versus CPP. The triphasic curve included a plateau region flanked by regions of relative ischemia (hypoxia) and hyperemia (hyperoxia). The plateau region shortened when cerebrovascular pressure reactivity was disrupted compared to when it was intact. Conclusions In this exploratory analysis of a multi-institution high-resolution physiology TBI database, PbtO2 seems to have a triphasic relationship with CPP, over the entire cohort. The CPP range over which the plateau exists is modified by the state of cerebrovascular reactivity. This indicates that in critically ill TBI patients admitted to ICU, PbtO2 may be reflective of CBF.

show abstract

Section: Introductionmentioning

confidence: 99%

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Gomez

Sekhon

Griesdale

et al. 2022

ICMx

View full text Add to dashboard Cite

show abstract

“…Using the Glasgow Outcome Scale-Extended outcome metric, no differences were found in the proportion of favorable neurologic outcomes between groups using PbtO 2 and ICP versus ICP monitoring alone at 6 months postinjury. However, in a pooled analysis, PbtO 2 + ICP-guided management resulted in a significantly reduced mortality risk at 6 months [12 ▪▪ ]. Two randomized clinical trials – Brain oxygen optimization in severe TBI, Phase 3 (BOOST3) and Impact of early optimization of brain oxygenation on neurologic outcome after severe traumatic brain injury (OXY-TC) are ongoing and will hopefully clarify any consequential benefits of PbtO 2 monitoring to improve long term outcomes.…”

Section: Acute Monitoringmentioning

confidence: 99%

Neurotrauma

Niziolek

Sandsmark

Pascual

2022

Current Opinion in Critical Care

View full text Add to dashboard Cite

Purpose of reviewThis review will highlight the latest research relevant to the clinical care of traumatic brain injury (TBI) patients over the last 2 years while underscoring the implications of these advances in the understanding of diagnosis, treatment, and prognosis of TBI.Recent findingsBrain tissue oxygenation monitoring can identify hypoperfusion as an adjunct to intracerebral pressure monitoring. Multiple biomarker assays are now available to help clinicians screen for mild TBI and biomarker elevations correlate with the size of intracranial injury. Beta-blocker exposure following TBI has demonstrated a survival benefit in those with TBI though the mechanism for this remains unknown. The optimal timing for venous thromboembolism prophylaxis for TBI patients is still uncertain.SummaryThe current characterization of TBI as mild, moderate, or severe fails to capture the complexity of the disease process and helps little with prognostication. Molecular biomarkers and invasive monitoring devices including brain tissue oxygenation and measures of cerebral autoregulation are being utilized more commonly and can help guide therapy. Extracranial complications following TBI are common and include infection, respiratory failure, coagulopathy, hypercoagulability, and paroxysmal sympathetic hyperactivity.

show abstract

“…Regional cerebral oxygenation may be measured using invasive catheters using different techniques to measure the PbtO 2 (sometimes referred to as PbrO 2 ). The BTF states level II evidence for an increased mortality risk of PbtO 2 < 29 mmHg and level III evidence for unfavorable outcome at a range below 15–20 mmHg [ 5 , 18 ]. Several PbtO 2 monitors on the market also monitor cerebral temperature, which in itself is important to monitor as it differs from core temperature monitoring [ 27 ], but has also been shown to influence intracranial dynamics [ 4 ].…”

Section: Invasive Monitoringmentioning

confidence: 99%

Current state of high-fidelity multimodal monitoring in traumatic brain injury

et al. 2022

View full text Add to dashboard Cite

Introduction Multimodality monitoring of patients with severe traumatic brain injury (TBI) is primarily performed in neuro-critical care units to prevent secondary harmful brain insults and facilitate patient recovery. Several metrics are commonly monitored using both invasive and non-invasive techniques. The latest Brain Trauma Foundation guidelines from 2016 provide recommendations and thresholds for some of these. Still, high-level evidence for several metrics and thresholds is lacking. Methods Regarding invasive brain monitoring, intracranial pressure (ICP) forms the cornerstone, and pressures above 22 mmHg should be avoided. From ICP, cerebral perfusion pressure (CPP) (mean arterial pressure (MAP)–ICP) and pressure reactivity index (PRx) (a correlation between slow waves MAP and ICP as a surrogate for cerebrovascular reactivity) may be derived. In terms of regional monitoring, partial brain tissue oxygen pressure (PbtO2) is commonly used, and phase 3 studies are currently ongoing to determine its added effect to outcome together with ICP monitoring. Cerebral microdialysis (CMD) is another regional invasive modality to measure substances in the brain extracellular fluid. International consortiums have suggested thresholds and management strategies, in spite of lacking high-level evidence. Although invasive monitoring is generally safe, iatrogenic hemorrhages are reported in about 10% of cases, but these probably do not significantly affect long-term outcome. Non-invasive monitoring is relatively recent in the field of TBI care, and research is usually from single-center retrospective experiences. Near-infrared spectrometry (NIRS) measuring regional tissue saturation has been shown to be associated with outcome. Transcranial doppler (TCD) has several tentative utilities in TBI like measuring ICP and detecting vasospasm. Furthermore, serial sampling of biomarkers of brain injury in the blood can be used to detect secondary brain injury development. Conclusions In multimodal monitoring, the most important aspect is data interpretation, which requires knowledge of each metric’s strengths and limitations. Combinations of several modalities might make it possible to discern specific pathologic states suitable for treatment. However, the cost–benefit should be considered as the incremental benefit of adding several metrics has a low level of evidence, thus warranting additional research.

show abstract

Effects of brain tissue oxygen (PbtO2) guided management on patient outcomes following severe traumatic brain injury: A systematic review and meta-analysis

Cited by 18 publications

References 31 publications

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Neurotrauma

Current state of high-fidelity multimodal monitoring in traumatic brain injury

Contact Info

Product

Resources

About