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Lung Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy Cover

Lung Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy

The Journal of Critical Care Medicine
Volume 9 (2023): Issue 2 (April 2023)
By: Celeste Dias,  Alexandre de Castro,  Rita Gaio,  Ricardo Silva,  Eduarda Pereira and  Elisabete Monteiro  
Open Access
|May 2023

Figures & Tables

Fig. 1.

Neurocritical Care Unit (NCCU) protocol for Traumatic Brain Injury and Intracranial Hypertension Management. Optimal cerebral perfusion pressure evaluated continuously at bedside with cerebrovascular reactivity index and intracranial pressure control below 20 mmHg are primary targets. ECG electrocardiogram, SpO2 pulse oximetry, ETCO2 endtidal carbon dioxide, ABP arterial blood pressure, NIRS cerebral oximetry with near-infrared light, BIS bispectral index, CVP central venous pressure, ICP intracranial pressure, ICM+ multimodal brain monitoring software, CAR cerebral autoregulation, PRx cerebrovascular reactivity index CPP cerebral perfusion pressure, CPPopt optimal CPP, PbtO2 brain tissue oxygen pressure, EEG electroencephalogram, PaO2 arterial oxygen pressure, PaCO2 arterial carbon dioxide pressure, Temp temperature, RASS Richmond agitation–sedation scale, BPS behavioral pain scale, Na+ serum sodium, SOsm serum osmolalityhead-CT head computerized tomography, CSF cerebral spinal fluid.
Neurocritical Care Unit (NCCU) protocol for Traumatic Brain Injury and Intracranial Hypertension Management. Optimal cerebral perfusion pressure evaluated continuously at bedside with cerebrovascular reactivity index and intracranial pressure control below 20 mmHg are primary targets. ECG electrocardiogram, SpO2 pulse oximetry, ETCO2 endtidal carbon dioxide, ABP arterial blood pressure, NIRS cerebral oximetry with near-infrared light, BIS bispectral index, CVP central venous pressure, ICP intracranial pressure, ICM+ multimodal brain monitoring software, CAR cerebral autoregulation, PRx cerebrovascular reactivity index CPP cerebral perfusion pressure, CPPopt optimal CPP, PbtO2 brain tissue oxygen pressure, EEG electroencephalogram, PaO2 arterial oxygen pressure, PaCO2 arterial carbon dioxide pressure, Temp temperature, RASS Richmond agitation–sedation scale, BPS behavioral pain scale, Na+ serum sodium, SOsm serum osmolalityhead-CT head computerized tomography, CSF cerebral spinal fluid.

Fig. 2.

Time evolution of PF ratio across the first ten days of admission for the whole sample according to ARDS definition of PFratio intervals by the Berlin Task Force (top). CPP evolution across the first ten days of admission for the whole sample and CPP definition interval according to Brain Trauma Foundation (bottom). PF ratio: ratio between oxygen arterial pressure and inspired fraction of oxygen; CPP: Cerebral Perfusion Pressure; HOB: Head of bed elevation (30o).
Time evolution of PF ratio across the first ten days of admission for the whole sample according to ARDS definition of PFratio intervals by the Berlin Task Force (top). CPP evolution across the first ten days of admission for the whole sample and CPP definition interval according to Brain Trauma Foundation (bottom). PF ratio: ratio between oxygen arterial pressure and inspired fraction of oxygen; CPP: Cerebral Perfusion Pressure; HOB: Head of bed elevation (30o).

Fig. 3.

Time evolution of PFratio (top), Ppl-PEEP (middle) and CPP-CPPopt (bottom), for each patient (fine lines), according to the Outcome (Dead or Alive) and Sex (Female, in red; Male, in black). The mean and 95% confidence band of the prediction model, based on the fixed-effects, are also pictured. PFratio: ratio between oxygen arterial pressure and inspired fraction of oxygen; Ppl–PEEP: difference between plateau pressure and PEEP (driving pressure); CPP-CPPopt: difference between cerebral perfusion pressure and optimal CPP.
Time evolution of PFratio (top), Ppl-PEEP (middle) and CPP-CPPopt (bottom), for each patient (fine lines), according to the Outcome (Dead or Alive) and Sex (Female, in red; Male, in black). The mean and 95% confidence band of the prediction model, based on the fixed-effects, are also pictured. PFratio: ratio between oxygen arterial pressure and inspired fraction of oxygen; Ppl–PEEP: difference between plateau pressure and PEEP (driving pressure); CPP-CPPopt: difference between cerebral perfusion pressure and optimal CPP.

Demographic, Monitoring, Management and Outcome data of patients with severe acute Traumatic Brain Injury_

Variables Mean±sd /Median (IQR)
Demographic Data
Number of PatientsTotal92
Multiple Trauma45 (49%)
Thoracic Trauma19 (21%)
Age (Years) 53 ± 21
GenderMale79 (86%)
Female13 (14%)
GCS at admission7 (IQR 5)
APACHE II19 ± 6
Apache II mortality (%)33 ± 17
CT Marshall Classification3 (IQR 2)
Monitoring and Management Data
FiO20.5 ± 0.13
PFratio305 ± 88
PaO2(mmHg)146.5 ± 28.5
PaCO2(mmHg)38.1 ± 3.7
SaO2(%)98.6 ± 0.74
RR (cycles/min)17 ± 4
MV (L/min)9.45 ± 2.18
PEEP (cmH20)6,2 ± 1,3
Ppl (cmH20)19.7 ± 4.8
DP=Ppl-PEEP (cmH20)15.9 ± 3.5
Shunt fraction (Qs/Qt) (%)16.3±6.7
Compliance43 ± 13.8
Fluid Balance (ml/d)171 ± 564
Therapy Intensity Level (TIL)2 (IQR 1)
HR (bpm)71.9 ± 10.5
ABP (mmHg)96.7 ± 7.0
ICP (mmHg)11.2 ± 5.8
CPP(mmHg)85.9 ± 7.4
PRx0.03 ± 0.19
CPPopt (mmHg)88.7 ± 8.5
CPP-CPPopt (mmHg)−2.8 ± 10.2
Outcome Data
LOS ICU (days)22 ± 26
LOS Hosp (days)48 ± 48
Mortality14 (15.2%)
GOS at 3 months3 (IQR 2)

Estimates from the final mixed-effects regression models for PFratio, CPP-CPPopt and Driving Pressure across time (10 days), adjusted for other variables of interest_

VariablesFIXED EFFECTSRANDOM EFFECT
CoefficientSt Errorp-valueSt deviation
Model for the time-effect on PFratio
Intercept436.4217.63<0.00159.25
Time (days)−27.124.56<0.001
Days22.1750.48<0.001
Female99.2823.39<0.001
PRx−49.9915.680.002
Ppl-Peep−5.340.97<0.001
Model for the time-effect of outcome on CPP-CPPopt
Intercept−2.371.580.1332.95
Dead−0.791.720.647
Time (days)−0.560.280.048
Time*Dead1.100.31<0.001
Model for the time-effect of outcome on Driving Pressure
Intercept14.761.10<0.0012.85
Dead−0.431.200.718
Time (days)0.680.15<0.001
Time*Dead−0.340.170.041
DOI: https://doi.org/10.2478/jccm-2023-0009 | Journal eISSN: 2393-1817 | Journal ISSN: 2393-1809
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Language: English
Page range: 97 - 105
Submitted on: Aug 11, 2022
|
Accepted on: Jan 31, 2023
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Published on: May 8, 2023
Published by: University of Medicine, Pharmacy, Science and Technology of Targu Mures
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
traumatic brain injury,
acute lung injury,
autoregulation,
optimal cerebral perfusion pressure,
pressure reactivity index,
driving pressure,
ARDS
Related subjects:
Medicine,
Clinical medicine,
Internal medicine,
Internal medicine, other,
Surgery,
Surgery, other,
Anaesthesiology,
Emergency medicine and intensive-care medicine

© 2023 Celeste Dias, Alexandre de Castro, Rita Gaio, Ricardo Silva, Eduarda Pereira, Elisabete Monteiro, published by University of Medicine, Pharmacy, Science and Technology of Targu Mures
This work is licensed under the Creative Commons Attribution 4.0 License.

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