Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study

Adams, Hadie; Donnelly, Joseph E.; Czosnyka, Marek; Kolias, Angelos G.; Helmy, Adel; Menon, David K.; Smielewski, Peter; Hutchinson, Peter J.

doi:10.1371/journal.pmed.1002353

Cited by 61 publications

(42 citation statements)

References 59 publications

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“…477 Prognostic models could also incorporate information that becomes available over time, such as repeated CT imaging, additional MRI scans, or temporal profiles of monitored parameters. 478 Such dynamic predictions are complex and require specific statistical techniques to capture repeated measures from the same patient. 479 Recently developed machine-learning techniques might hold promise for use with complex data structures, but they have performed inconsistently in predicting outcome after TBI.…”

Section: Advancing the Science Of Prognosis In Tbimentioning

confidence: 99%

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

Maas¹,

Menon²,

Adelson³

et al. 2017

The Lancet Neurology

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A concerted effort to tackle the global health problem posed by traumatic brain injury (TBI) is long overdue. TBI is a public health challenge of vast, but insufficiently recognised, proportions. Worldwide, more than 50 million people have a TBI each year, and it is estimated that about half the world's population will have one or more TBIs over their lifetime. TBI is the leading cause of mortality in young adults and a major cause of death and disability across all ages in all countries, with a disproportionate burden of disability and death occurring in low-income and middle-income countries (LMICs). It has been estimated that TBI costs the global economy approximately $US400 billion annually. Deficiencies in prevention, care, and research urgently need to be addressed to reduce the huge burden and societal costs of TBI. This Commission highlights priorities and provides expert recommendations for all stakeholders—policy makers, funders, health-care professionals, researchers, and patient representatives—on clinical and research strategies to reduce this growing public health problem and improve the lives of people with TBI.Additional co-authors: Endre Czeiter, Marek Czosnyka, Ramon Diaz-Arrastia, Jens P Dreier, Ann-Christine Duhaime, Ari Ercole, Thomas A van Essen, Valery L Feigin, Guoyi Gao, Joseph Giacino, Laura E Gonzalez-Lara, Russell L Gruen, Deepak Gupta, Jed A Hartings, Sean Hill, Ji-yao Jiang, Naomi Ketharanathan, Erwin J O Kompanje, Linda Lanyon, Steven Laureys, Fiona Lecky, Harvey Levin, Hester F Lingsma, Marc Maegele, Marek Majdan, Geoffrey Manley, Jill Marsteller, Luciana Mascia, Charles McFadyen, Stefania Mondello, Virginia Newcombe, Aarno Palotie, Paul M Parizel, Wilco Peul, James Piercy, Suzanne Polinder, Louis Puybasset, Todd E Rasmussen, Rolf Rossaint, Peter Smielewski, Jeannette Söderberg, Simon J Stanworth, Murray B Stein, Nicole von Steinbüchel, William Stewart, Ewout W Steyerberg, Nino Stocchetti, Anneliese Synnot, Braden Te Ao, Olli Tenovuo, Alice Theadom, Dick Tibboel, Walter Videtta, Kevin K W Wang, W Huw Williams, Kristine Yaffe for the InTBIR Participants and Investigator

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Section: Advancing the Science Of Prognosis In Tbimentioning

confidence: 99%

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

Maas¹,

Menon²,

Adelson³

et al. 2017

The Lancet Neurology

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1,759

1,261

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“…The mechanisms of autoregulation of CBF differ with changes in ICP. 13 Respiratory dysfunction and loss of autoregulation is common in patients with TBI, 14 and a 1% change in PaCO 2 can lead to changes of up to 4% in CBF. 15 Prehospital data evaluating the use of ETCO 2 are limited, but are not consistent with in-hospital findings; leading to some criticism of the use of ETCO 2 to guide ventilation.…”

Section: Introductionmentioning

confidence: 99%

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Price¹,

Sandbach²,

Ercole

et al. 2020

Emerg Med J

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ObjectivesIn the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0–4.5 kPa (30.0–33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO2–PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO2–PaCO2 gradient of TBI patients at hospital arrival.MethodsA retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% CI. ETCO2–PaCO2 gradient data were compared with a two-tailed, unpaired, t-test.Results107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO2–PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and −0.2 (95% CI −0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2–PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg).ConclusionThere is only moderate correlation of ETCO2 and PaCO2 at hospital arrival in patients with serious TBI. The mean ETCO2–PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO2 measurement.

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“…Intracranial pressure (ICP) is well known to be associated with outcome in adult traumatic brain injury (TBI), with higher sustained levels of ICP linked to worse global outcome, and particularly higher mortality [1, 3, 5, 9, 11]. Various studies to date have documented such associations, with defined treatment thresholds providing one of the main therapeutic targets in the critical care management of the moderate/severe TBI patient [3, 9].…”

Section: Introductionmentioning

confidence: 99%

Compensatory-reserve-weighted intracranial pressure versus intracranial pressure for outcome association in adult traumatic brain injury: a CENTER-TBI validation study

et al. 2019

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Background Compensatory-reserve-weighted intracranial pressure (wICP) has recently been suggested as a supplementary measure of intracranial pressure (ICP) in adult traumatic brain injury (TBI), with a single-center study suggesting an association with mortality at 6 months. No multi-center studies exist to validate this relationship. The goal was to compare wICP to ICP for association with outcome in a multi-center TBI cohort. Methods Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived ICP and wICP (calculated as wICP = (1 − RAP) × ICP; where RAP is the compensatory reserve index derived from the moving correlation between pulse amplitude of ICP and ICP). Various univariate logistic regression models were created comparing ICP and wICP to dichotomized outcome at 6 to 12 months, based on Glasgow Outcome Score—Extended (GOSE) (alive/dead—GOSE ≥ 2/GOSE = 1; favorable/unfavorable—GOSE 5 to 8/GOSE 1 to 4, respectively). Models were compared using area under the receiver operating curves (AUC) and p values. Results wICP displayed higher AUC compared to ICP on univariate regression for alive/dead outcome compared to mean ICP (AUC 0.712, 95% CI 0.615–0.810, p = 0.0002, and AUC 0.642, 95% CI 0.538–746, p < 0.0001, respectively; no significant difference on Delong’s test), and for favorable/unfavorable outcome (AUC 0.627, 95% CI 0.548–0.705, p = 0.015, and AUC 0.495, 95% CI 0.413–0.577, p = 0.059; significantly different using Delong’s test p = 0.002), with lower wICP values associated with improved outcomes ( p < 0.05 for both). These relationships on univariate analysis held true even when comparing the wICP models with those containing both ICP and RAP integrated area under the curve over time ( p < 0.05 for all via Delong’s test). Conclusions Compensatory-reserve-weighted ICP displays superior outcome association for both alive/dead and favorable/unfavorable dichotomized outcomes in adult TBI, through univariate analysis. Lower wICP is associated with better global outcomes. The results of this study provide multi-center validation of those seen in a previous single-center study. Electronic supplementary material The online version of this article (10.1007/s00701-019-03915-3) contains supplementary material, which is available to authorized users.

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Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study

Cited by 61 publications

References 59 publications

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study

Compensatory-reserve-weighted intracranial pressure versus intracranial pressure for outcome association in adult traumatic brain injury: a CENTER-TBI validation study

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