Patient-specific thresholds of intracranial pressure in severe traumatic brain injury
Patient-specific thresholds of intracranial pressure in severe traumatic brain injury
复制标题
DOI：
10.3171/2014.1.jns131292
复制
发表时间：
2014-04-01
影响因子：
4.1
通讯作者：
Czosnyka, Marek
中科院分区：
文献类型：
--
作者：
Lazaridis, Christos;DeSantis, Stacia M.;Czosnyka, Marek
物体。在连续监测压力反应性指数(PRX)的基础上，通过绘制颅内压与PRX的关系图，定义了个体化的颅内压阈值。这些研究人员假设，与推荐的20和25 mm Hg通用阈值得出的ICP剂量相比，基于单独评估的ICP阈值的“ICP剂量”与6个月的结果更密切相关。本研究对327例重型颅脑损伤患者前瞻性收集的资料进行了回顾性分析。个体化阈值从Prx与ICP的曲线图中直观地识别出来；Prx>；0.2是临界值。然后计算颅内压剂量，作为曲线下的累积面积高于定义的阈值，绘制出颅内压随时间变化的曲线。术语“剂量20”(D20)指的是20毫米汞柱的ICP阈值；标记物D25和DPRx的计算方法类似。独立的Logistic回归模型以死亡作为结果，以每种剂量作为预测因素，既单独适用，也适用于协变量调整。采用5次交叉验证的受试者工作特征AUC分析评价各剂量对死亡率的区分能力。在224名患者(68%)中，基于PRX的明确可识别的阈值是可能的。D20(0.75，95%CI 0.68-0.81)和D25(0.77，95%CI 0.70-0.83)的曲线下面积(AUC)最大(AUC 0.81，95%CI 0.74-0.87)，在交叉验证模型中，DPRx仍然是最好的死亡率判别因子(DPRx：AUC 0.77[95%CI 0.68-0.89]；D20：0.72[95%CI 0.66-0.81]；D25：0.65[95%可信区间0.56~0.73])。作者基于脑血管压力反应性的连续监测，通过计算患者特定的颅内压剂量，探讨了不同的颅内压阈值对预后的重要性。他们发现，这些个性化的颅内高压剂量比从20和25毫米汞柱的普遍阈值得出的剂量更能预测死亡。PRX可以提供一种方法，可以指导对ICP阈值的个体化。
Object. Based on continuous monitoring of the pressure reactivity index (PRx), the authors defined individualized intracranial pressure (ICP) thresholds by graphing the relationship between ICP and PRx. These investigators hypothesized that an "ICP dose" based on individually assessed ICP thresholds would correlate more closely with the 6-month outcome when compared with ICP doses derived by the recommended universal thresholds of 20 and 25 mm Hg.Methods. This study was a retrospective analysis of prospectively collected data from 327 patients with severe traumatic brain injury.Results. Individualized thresholds were visually identified from graphs of PRx versus ICP; PRx > 0.2 was the cutoff. Intracranial pressure doses were then computed as the cumulative area under the curve above the defined thresholds in graphing ICP versus time. The term "Dose 20" (D20) was used to refer to an ICP threshold of 20 mm Hg; the markers D25 and DPRx were calculated similarly. Separate logistic regression models were fit with death as the outcome and each dose as the predictor, both alone and adjusted for covariates. The discriminative ability of each dose for mortality was assessed by receiver operating characteristic AUC analysis in which 5-fold cross-validation was used. A clearly identifiable PRx-based threshold was possible in 224 patients (68%). The DPRx (AUC 0.81, 95% CI 0.74-0.87) was found to have the highest area under the curve (AUC) over both D20 (0.75, 95% CI 0.68-0.81) and D25 (0.77, 95% CI 0.70-0.83); in the cross-validation model, DPRx remained the best discriminator of mortality (DPRx: AUC 0.77 [95% CI 0.68-0.89]; D20: 0.72 [95% CI 0.66-0.81]; and D25: 0.65 [95% CI 0.56-0.73]).Conclusions. The authors explored the importance of different ICP thresholds for outcome by calculating patient-specific ICP doses based on the continuous monitoring of cerebrovascular pressure reactivity. They found that these individualized doses of intracranial hypertension were stronger predictors of death than doses derived from the universal thresholds of 20 and 25 mm Hg. The PRx could offer a method that can be directed toward individualizing the ICP threshold.