Optimal Cerebral Perfusion Pressure Management at Bedside: A Single-Center Pilot Study
Optimal Cerebral Perfusion Pressure Management at Bedside: A Single-Center Pilot Study
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DOI：
10.1007/s12028-014-0103-8
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发表时间：
2015-08-01
影响因子：
3.5
通讯作者：
Czosnyka, Marek
中科院分区：
文献类型：
--
作者：
Dias, Celeste;Silva, Maria Joao;Czosnyka, Marek
指南建议脑灌注压（CPP）值为50-70 mmHg，颅内压低于20 mmHg，用于管理急性创伤性脑损伤（TBI）。然而，由于患者具有不同的灌注阈值，因此适当的个体目标仍然没有得到很好的解决。脑自动调节的床旁评估可能有助于优化个体CPP引导的treatment.To评估工作人员的依从性和结果的影响的一种新的方法的自动调节引导的治疗（CPPopt）的基础上连续评估脑血管反应性（PRx）。基于先前的4小时窗口，自动估计每分钟CPPopt，作为具有最低PRx的CPP，表明最佳脑血管压力反应性。尽可能使用CPPopt目标管理患者，否则根据一般/国际指南管理CPP。此外，其他离线CPPopt估计值使用脑氧饱和度（COx-CPPopt）、脑组织氧合（ORxs-CPPopt）和脑血流量（CBFx-CPPopt）计算。在整个监测期间，11例患者（61%）的CPPopt呈U形曲线，5例患者（28%）呈上升或下降曲线，仅2例患者（11%）无拟合曲线。真实的CPP与计算的CPPopt显著相关（r = 0.83，p < 0.0001）。保留的自动调节与入院时更高的格拉斯哥昏迷评分（p = 0.01）和更好的结局（p = 0.01）相关。我们证明了真实的CPP和CPPopt之间存在较大差异（> 10 mm Hg）的患者更有可能出现不良结局（p = 0.04）。CPPopt和其他估计值之间的比较显示了相似的精度限制。COx-CPPopt（NIRS）的偏倚最低（-0.1mmHg），利用脑血管压力反应性在床旁进行针对性的个体CPP管理是可行的。与CPPopt的较大偏差似乎与不良结局相关。使用非侵入性CO（NIRS）的COx-CPPopt方法值得进一步评价。
Guidelines recommend cerebral perfusion pressure (CPP) values of 50-70 mmHg and intracranial pressure lower than 20 mmHg for the management of acute traumatic brain injury (TBI). However, adequate individual targets are still poorly addressed, since patients have different perfusion thresholds. Bedside assessment of cerebral autoregulation may help to optimize individual CPP-guided treatment.To assess staff compliance and outcome impact of a new method of autoregulation-guided treatment (CPPopt) based on continuous evaluation of cerebrovascular reactivity (PRx).Prospective pilot study of severe TBI adult patients managed with continuous multimodal brain monitoring in a single Neurocritical Care Unit (NCCU). Every minute CPPopt was automatically estimated, based on the previous 4-h window, as the CPP with the lowest PRx indicating the best cerebrovascular pressure reactivity. Patients were managed with CPPopt targets whenever possible and otherwise CPP was managed following general/international guidelines. In addition, other offline CPPopt estimates were calculated using cerebral oximetry (COx-CPPopt), brain tissue oxygenation (ORxs-CPPopt), and cerebral blood flow (CBFx-CPPopt).Eighteen patients with a total multimodal brain monitoring time of 5,520 h were enrolled. During the total monitoring period, 11 patients (61 %) had a CPPopt U-shaped curve, 5 patients (28 %) had either ascending or descending curves, and only 2 patients (11 %) had no fitted curve. Real CPP correlated significantly with calculated CPPopt (r = 0.83, p < 0.0001). Preserved autoregulation was associated with greater Glasgow coma score on admission (p = 0.01) and better outcome (p = 0.01). We demonstrated that patients with the larger discrepancy (> 10 mm Hg) between real CPP and CPPopt more likely have had adverse outcome (p = 0.04). Comparison between CPPopt and the other estimates revealed similar limits of precision. The lowest bias (-0.1 mmHg) was obtained with COx-CPPopt (NIRS).Targeted individual CPP management at the bedside using cerebrovascular pressure reactivity seems feasible. Large deviation from CPPopt seems to be associated with adverse outcome. The COx-CPPopt methodology using non-invasive CO (NIRS) warrants further evaluation.