invasive multimodal monitoring in tbitake to or for immediate ftp craniectomy, evacuation of ich,...
TRANSCRIPT
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Invasive multimodal monitoring in TBI
Critical Care Canada Forum 2019
Donald Griesdale MD MPHAssociate Professor
Department of Anesthesiology, Pharmacology & Therapeutics
Divisions of Critical Care Medicine & Neurology
University of British Columbia
@dgriesdale [email protected]
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Speaker Disclosures
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PhysicalExamination
ICP
Microdialysis
PbtO2
CBF
Auto-regulation
Jugular bulb
EEG
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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http://braintrauma.org
Monitoring guidelines (ICP)
• Salvageable patients with severe TBI
(GCS 3 – 8 post resuscitation)
AND
• Abnormal CT Head
CPP Thresholds:
• Recommended CPP between
60 – 70 mmHg.
Treat ICP:
• Treating ICP above 22 mmHg is
recommended
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GCS≤8 + abnormal CT: 53 – 63% had increased ICP
GCS≤8 + normal CT: 13 % had increased ICP
Patients >40 years, SBP < 90 mmHg or posturing had similar rates of increased ICP as group with abnormal CT head
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Important events of
1982
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Collaboration with ICU
and Neurosurgery
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Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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ICM+
Autoregulation indices with PRx
PbtO2
ICP
Microdialysis
Bowman (CBF)
Neuromonitoring
Platform
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PbtO2
ICP
ICM+
Intravascular
coolingMicrodialysis
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PbO2 is a measure of CBF under normoxia
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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22 yo male with DAI + Fat Embolism Syndrome
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Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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CPP
PbO2
90
60
20
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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PbrO2
PRx
CPP ~ 50
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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PbrO2
PRx
CPP ~ 85
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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Crit Care Med. 2019 Jul;47:960
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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CCM 2017;45:1907
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
sTBI who required ICP monitoring
ICP onlyn=62
ICP + PbtO2n=57
Outcomes• Degree of brain tissue hypoxia (PbtO2 <20 mmHg)• Safety & Feasibility• Clinical Outcomes
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CCM 2017;45:1907
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
sTBI who required ICP monitoring
ICP onlyn=62
ICP + PbtO2n=57
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CCM 2017;45:1907
Proportion of time with PbtO2 <20mmHg
ICP only44%
ICP + PbtO215%
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
sTBI who required ICP monitoring
ICP onlyn=62
ICP + PbtO2n=57
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CCM 2017;45:1907
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
![Page 26: Invasive multimodal monitoring in TBITake to OR for immediate FTP craniectomy, evacuation of ICH, and resection of AVM Placement of EVD Introduction Our platform P bt O 2 monitoring](https://reader030.vdocuments.site/reader030/viewer/2022040718/5e2736523887e7519d2dccbc/html5/thumbnails/26.jpg)
CCM 2017;45:1907
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
![Page 27: Invasive multimodal monitoring in TBITake to OR for immediate FTP craniectomy, evacuation of ICH, and resection of AVM Placement of EVD Introduction Our platform P bt O 2 monitoring](https://reader030.vdocuments.site/reader030/viewer/2022040718/5e2736523887e7519d2dccbc/html5/thumbnails/27.jpg)
CCM 2017;45:1907
What PbtO2 threshold do you use?
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
glutamate
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Increased Lactate / Pyruvate Ratio
IschemiaMitochondrial
dysfunction
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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17 year old female
Sudden onset headache and became unresponsive
Vomited and urinary incontinence
EHS arrives, GCS 3, pupils reactive and hemodynamically stable
Transferred to VGH through a regional hospital Large left frontal ICH from AVM rupture
Left pupil 5 mm and fixed
Right pupil 3 mm and reactive
Take to OR for immediate FTP craniectomy, evacuation of ICH, and resection of AVM
Placement of EVD
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
![Page 34: Invasive multimodal monitoring in TBITake to OR for immediate FTP craniectomy, evacuation of ICH, and resection of AVM Placement of EVD Introduction Our platform P bt O 2 monitoring](https://reader030.vdocuments.site/reader030/viewer/2022040718/5e2736523887e7519d2dccbc/html5/thumbnails/34.jpg)
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CPP
PbtO2
• ICP 8 – 14 via EVD
• Temperature 36C
• Sedated on midazolam 20mg/hr & fentanyl 100mcg/hr
• Serum Na 148 mEq/L
• EEG: burst suppression
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CBF CBV MTT
Evolving L MCA and bilateral ACA infarcts
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CPP
PbtO2
• Oligemia
• Diffusion hypoxia
• Infarct
• Increased CMRO2
Why PbtO2 persistently low?
Increased MAP
Increased PaO2
Nothing to do
Hypothermia
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LP ratio = 31
CPP
PbtO2
Temp
LP ratioLP ratio = 320
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Invasive multimodal neuromonitoring helps individualize therapy
Impact on neurologic outcomes remains unclear
Introduction
Our platform
PbtO2 monitoring
Microdialysis
Case example
Conclusion
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Thank you!