Group‐based trajectory modeling of intracranial pressure in patients with acute brain injury: Results from multi‐center ICUs, 2008–2019

Abstract

Objective:The objective of the study was to characterize the longitudinal, dynamic intracranial pressure (ICP) trajectory in acute brain injury (ABI) patients admitted to intensive care unit (ICU) and explore whether it added sights over traditional thresholds in predicting outcomes.Methods: ABI patients with ICP monitoring were identified from two public databases named Medical Information Mart for the Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). Group-based trajectory modeling (GBTM) was employed to identify 4-h ICP trajectories in days 0-5 post-ICU admission. Then, logistic regression was used to compare clinical outcomes across distinct groups. To further validate previously reported thresholds, we created the receiver operating characteristic (ROC) curve in our dataset.Results: A total of 810 eligible patients were ultimately enrolled in the study. GBTM analyses generated 6 distinct ICP trajectories, differing in the initial ICP, evolution pattern, and number/proportion of spikes >20/22 mmHg. Compared with patients in "the highest, declined then rose" trajectory, those belonging to the "lowest, stable," "low, stable," and "medium, stable" ICP trajectories were at lower risks of 30-day mortality (odds ratio [OR] 0.04; 95% confidence interval [CI] 0.01, 0.21), (OR 0.04; 95% CI 0.01, 0.19), (OR 0.08; 95% CI 0.01, 0.42), respectively. ROC analysis demonstrated an unfavorable result, for example, 30-day mortality in total cohort: an area under the curve (AUC): 0.528, sensitivity: 0.11, and specificity: 0.94. Conclusions:This study identified three ICP trajectories associated with elevated risk, three with reduced risks for mortality during ICU hospitalization. Notably, a fixed ICP threshold should not be applied to all kinds of patients. GBTM, a granular method for describing ICP evolution and their association with clinical outcomes, may add to the current knowledge in intracranial hypertension treatment.

Mecanismos de estabilização do paciente neurocrítico

“…A pressão intracraniana (PIC) é uma das principais preocupações em relação ao neuro crítico na unidade de terapia intensiva (UTI), segundo um estudo realizado por Yang et al (2022), foi confirmado que a hipertensão intracraniana (definida como valores de PIC superiores a 20 -25 mmHg) é considerada patologicamente relevante devido à sua relação com a mortalidade (Kharouba et al, 2023) De acordo com um estudo efetuado por Hawryluk et al (2019), bloqueadores neuromusculares (BNMs) também mostraram eficácia para redução da HIC, tendo em vista que esses interceptam a transmissão do impulso nervoso, consequentemente, inibindo os movimentos do paciente neuro crítico, pois a movimentação desse enfermo aumenta a PIC, assim como os sedativos (Midazolan, Propofol e Dexmetomidina) que visam a manutenção da hemodinâmica neuronal (BAUERSCHMIDT et al, 2023). Porém, ressaltam precauções para o uso desses fármacos, destaca-se, portanto, que a utilização precoce, rotineira e prolongada dessas substâncias em pacientes neuro críticos é prejudicial.…”

“…Quando acontece uma elevação do volume de um destes conteúdos intracranianos, ocorre a Hipertensão Intracraniana (HIC), a qual deve ser tratada se insistir acima de 20 -22 mmHg. (Yang et al, 2022;Treggiari et al, 2023).…”

Effects of 24-hour urine-output trajectories on the risk of acute kidney injury in critically ill patients with cirrhosis: a retrospective cohort analysis

“…Yang et al. found that the prognosis of patients with acute brain injury was not only associated with the level of intracranial pressure at baseline, but also with dynamic changes in intracranial pressure [ 19 ]. In addition, dynamic monitoring of urine output over 24 h has been shown to be valuable in predicting AKI in septic patients [ 20 ].…”

The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management

“…Moreover, even for the same patient, adjusting ideal cerebral perfusion may require arterial blood pressure (ABP) changes during periods of physiological instability following injury [ 11 , 12 ]. Hence, determining the most vulnerable periods for tissue hypoxia and cellular dysfunction [ 13 , 14 ] can be challenging [ 15 – 18 ]. In this context, intracranial compliance (ICC) impairment, the threshold with which intracranial volume has overpassed the inner compensatory reserve [ 19 , 20 ], can be a more reliable target than ICP alone [ 21 ].…”