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Background: Brain tissue oxygenation (PbtO2)-guided management facilitates treatment of reduced PbtO2 episodes potentially conferring survival and
outcome advantages in severe traumatic brain injury (TBI). To date, the
nature and effectiveness of commonly used interventions in correcting
compromised PbtO2 in TBI remains unclear. We sought to identify the most
common interventions used in episodes of compromised PbtO2 and to
analyze which were effective.
Methods: A retrospective 7-year review of consecutive severe TBI patients
with a PbtO2 monitor was conducted in a Level I trauma centers intensive
care unit or neurosurgical registry. Episodes of compromised PbtO2 (defined
as 20 mm Hg for 0.25 4 hours) were identified, and clinical interventions
conducted during these episodes were analyzed. Response to treatment was
gauged on how rapidly (T) PbtO2 normalized (20 mm Hg) and how great
the PbtO2 increase was (PbtO2). Intracranial pressure (ICP) and cerebral
perfusion pressure (CPP) also were examined for these episodes.
Results: Six hundred twenty-five episodes of reduced PbtO2 were identified
in 92 patients. Patient characteristics were: age 41.2 years, 77.2% men, and
Injury Severity Score and head or neck Abbreviated Injury Scale score of
34.0 9.2 and 4.9 0.4, respectively. Five interventions: narcotics or
sedation, pressors, repositioning, FIO2/PEEP increases, and combined sedation or narcotics pressors were the most commonly used strategies.
Increasing the number of interventions resulted in worsening the time to
PbtO2 correction. Triple combinations resulted in the lowest ICP and dual
combinations in the highest CPP (p 0.05).
Conclusion: Clinicians use a limited number of interventions when correcting compromised PbtO2. Using strategies employing many interventions
administered closely together may be less effective in correcting PbO2, ICP,
and CPP deficits. Some PbtO2 deficits may be self-limited.
Key Words: Brain tissue oxygenation, Traumatic brain injury, Treatment
interventions, PbtO2-guided management, Clinical practice guidelines.
(J Trauma. 2011;70: 535546)
METHODS
Patient Population
All blunt TBI patients admitted to the intensive care unit
(ICU) of an academic Level I trauma center who had a parenchymal intracranial monitor able to measure partial brain tissue
oxygen tension (PbtO2) between October 2001 and September
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
535
Pascual et al.
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
Physiologic Monitors
Heart rate, arterial line blood pressures, and arterial oxygen saturations (SaO2) were monitored continuously (Component Monitoring System M1046-9090C: Hewlett Packard,
Andover, MA). The MAP was derived from arterial lines with
transducers leveled at the phlebostatic axis. Central venous
pressures and pulmonary artery pressures were followed in patients
with intravascular depletion or cardiopulmonary compromise.
80 100 mL/h), (7) anticonvulsant prophylaxis with phenytoin for 1 week or longer if seizures occurred, and (8) packed
red blood cell transfusion if their Hgb was 7.
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
Figure 1. Institutional algorithm for severe TBI management. ET tube, endotracheal tube; ABG, arterial blood gas; SjvO2, jugular venous bulb oxygenation; Hgb, hemoglobin; PaCO2, partial carbon dioxide tension of blood.
administered during this time period were collected. Basic demographics (age, sex, and race) and illness scores (Injury Severity Score, Acute Physiology and Chronic Health Evaluation,
Abbreviated Injury Scale, and Glasgow Coma Score [GCS])
were collected for each patient.
Outcome Assessment
Discharge disposition was recorded for all patients. In
patients who survived past discharge, a functional outpatient
evaluation interview 3- to 6-month postdischarge was obtained
using the Glasgow Outcome Score-extended (GOS-e)19 and
modified Rankin Scale (mRS)20 scores. These data are acquired
2011 Lippincott Williams & Wilkins
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
Pascual et al.
TABLE 1.
Description of Interventions
Intervention
Paralytics
Cooling
Pressors
FIO2/PEEP increases
Narcotics/sedation
Repositioning
Fluids
Osmotherapy
PRBCs
Ionotropes
FFP
BOMO-Coded Treatments
Any addition/increase in dose of neuromuscular
blocking agents
Any event where body temperature was
purposefully reduced below normothermia
Any addition/increase in dose of norepinephrine,
phenylephrine, epinephrine, or vasopressin
Any net increase of inspired oxygen or positive
end expiratory pressure
Any addition/increase in dose of opiods,
benzodiazepines, or propofol
Any turn to right, left, head-of-bed elevation,
lowering
Any bolus of crystalloids or colloids (excluding
transfusion therapy)
Any boluses of mannitol or hypertonic saline
Any transfusion of packed red blood cells
Any addition/increase in dose of milrinone,
dopamine, or dobutamine
Any transfusion of fresh frozen plasma
PRBC, packed red blood cells; FFP, fresh frozen plasma; PEEP, positive end
expiratory pressure.
sented as mean SD unless otherwise specified and a twotailed p value of 0.05 was considered statistically significant.
RESULTS
Study Population
Four hundred sixty-two (462) patients who had 1,601
episodes of compromised PbtO2 (20 mm Hg) were identi-
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
TABLE 2.
Characteristic
Sex (male/female)
Age
ISS
Head AIS
ED arrival GCS
Patients receiving 1 ICP monitor
Patients receiving and SjO2 monitor
Patients with craniotomy/craniectomy
Hospital LOS (days)
Hospital mortality
Post discharge GOS-e
Post discharge mRS
72/20 (78.2/21.8%)
41 19
34 12
4.88 0.42
64
24 (26%)
8 (9.1%)
31 (34%)
24.6 (0146)
25 (27.2%)
33
42
AIS, Abbreviated Injury Scale; ED, emergency department; ISS, Injury Severity
Score; SjO2, jugular bulb venous oxygen; LOS, length of stay; GOS-e, Glasgow
Outcome Score-extended; mRS, modified Rankin Scale.
TABLE 3.
No treatment
Any treatment
p
T (h)
280
345
0.84 0.63
1.15 0.85
0.05
9.12 9.14
9.77 10.43
1.0
No intervention
Any 1 intervention
Any 2 interventions
Any 3 interventions
Any 4 interventions
Any 5 interventions
Percentage
of Treated
Mean (h)*
Range
SD
280
187
101
41
11
3
54.2
30.0
11.9
3.2
0.8
0.84
1.03
1.13
1.49
1.74
2.42
0.253.58
0.253.97
0.253.83
0.253.50
0.333.75
0.583.83
0.63
0.79
0.82
0.86
1.26
1.66
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
Pascual et al.
No. of Intervention(s)
1
1
1
2
2
2
5
5
2
4
vs.
vs.
vs.
vs.
vs.
vs.
vs.
vs.
vs.
vs.
3
4
5
5
4
3
3
4
1
3
0.00
0.01
0.01
0.01
0.03
0.03
0.07
0.24
0.33
0.38
TABLE 6.
Intervention 1
Intervention 2
Narcotics/sedation
Pressors
Repositioning
FIO2/PEEP increases
Sedation/narcotics
Fluids
Sedation/narcotics
Sedation/narcotics
Sedation/narcotics
Pressors
Sedation/narcotics
Pressors
FIO2/PEEP increases
Reposition
Fluids
Fluids
Osmotherapy
60
51
27
24
19
9
9
9
8
7
5
1.02 0.77
0.94 0.87
1.11 0.67
0.99 0.51
1.11 0.86
1.22 0.89
1.71 1.18
1.11 0.86
0.98 0.35
1.25 0.81
0.25 0.53
10.6 12.1
7.9 8.4
9.1 11.8
9.5 8.8
9.5 7.9
11.9 12.7
9 5.3
10.1 9.8
7.2 4.8
7.6 6.9
16.9 14.5
TABLE 7.
Intervention
Paralytics
Cooling
Pressors
FIO2/PEEP increases
Narcotics/sedation
Repositioning
Fluids
Osmotherapy
PRBCs
Ionotropes
FFP
Any single treatment
Mean (h)
Range
SD
Range
SD
4
4
51
24
60
27
9
7
1
0
0
187
0.4
0.91
0.94
0.99
1.02
1.11
1.22
1.33
3.65
N/A
N/A
1.03
0.250.5
0.471.5
0.253.97
0.272.5
0.253.0
0.253.0
0.253.2
0.333.7
3.653.65
N/A
N/A
0.254.0
0.12
0.51
0.88
0.52
0.77
0.67
0.89
1.07
0
N/A
N/A
0.68
8.4
6.7
7.9
9.5
10.6
9.1
11.9
14.4
27.5
N/A
N/A
11.8
5.714
1.718
1.346.6
0.340
6.8 to 62.7
0.457
1.140
3.250
2828
N/A
N/A
6.863
4.01
7.8
8.35
8.83
12.16
11.81
12.68
16.85
0
N/A
N/A
10.31
PEEP, positive end expiratory pressure; PRBC, packed red blood cells; FFP, fresh frozen plasma.
540
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
TABLE 8.
SD
SD
1
2
3
4
4
5
5
2
19
8
1
4
1
6
9
2
7
3
9
1
2
1
1
1
101
0.33 (0.330.33)
0.54 (0.420.7)
0.63 (0.50.75)
0.67 (0.421.0)
0.67 (0.421.0)
0.78 (0.251.2)
0.82 (0.251.5)
0.94 (0.881.0)
0.99 (0.253.2)
0.99 (0.501.5)
1.00 (11)
1.01 (0.571.7)
1.03 (1.031.03)
1.06 (0.333.5)
1.11 (0.372.9)
1.13 (0.51.8)
1.25 (0.252.8)
1.31 (0.52.6)
1.74 (0.333.8)
2.00 (22)
2.08 (1.23.0)
2.58 (2.62.6)
3.00 (33)
3.00 (33)
1.28 (0.253.8)
N/A
0.18
0.13
0.26
0.26
0.46
0.53
0.08
0.83
0.35
N/A
0.48
N/A
1.22
0.86
0.88
0.81
1.1
1.26
N/A
1.3
N/A
N/A
N/A
0.65
11.9 (11.911.9)
6.8 (3.210.4)
5.3 (1.89.7)
11.0 (1.232)
11.0 (1.232)
11.4 (0.637.4)
16.9 (4.837)
10.0 (6.2138)
8.4 (1.617.5)
7.3 (3.117.5)
14.1 (14.114.1)
4.9 (3.26.6)
1.4 (1.41.4)
9.6 (1.817.8)
10.1 (2.2 to 33.6)
42.4 (5.879.0)
7.6 (1.721.3)
6.0 (4.78.0)
8.2 (2.214.6)
4.4 (4.44.4)
3.9 (2.65.2)
13.2 (13.213.2)
2.8 (2.82.8)
2.8 (2.82.8)
9.6 (2.2 to 79)
N/A
5.09
4.03
14.27
14.27
15.27
14.48
5.37
4.92
4.84
N/A
1.63
N/A
5.92
9.75
51.76
6.94
1.74
4.88
N/A
1.84
N/A
N/A
N/A
9.82
PEEP, positive end expiratory pressure; PRBC, packed red blood cells; FFP, fresh frozen plasma.
TABLE 9.
and CPP
N
Intervention 1
Narcotics/sedation
Pressors
Repositioning
FIO2/PEEP
increases
19 Sedation/narcotics
9 Fluids
9 Sedation/narcotics
9 Sedation/narcotics
8 Sedation/narcotics
7 Pressors
5 Sedation/narcotics
Intervention 2
60
51
27
24
ICP
CPP
2.6 11.2
1.4 7.5
0.8 7.8
0.1 4.8
4.0 16.6
8.3 18.9
10.2 12.8
5.3 15.4
1.2 6.8
0.8 2.8
2.1 5.3
FIO2/PEEP increases
Reposition
0.5 4.4
Fluids
2.0 4.2
Fluids
0.3 2.5
Osmotherapy
7.8 7.9
Pressors
9.6 22.7
6.8 16.9
7.1 10.2
20 35.2
4.7 7.7
13.9 26.2
1.5 12.3
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
Pascual et al.
DISCUSSION
In this study, we examined 92 severe TBI patients with
625 episodes of compromised PbtO2 (20 mm Hg for
0.25 4 hours) and how these episodes were treated. We
observed the following: (1) 44% of episodes were corrected
without specific treatment; (2) most episodes of compromised
PbtO2 could be successfully treated with one or two interventions and none required more than five interventions; (3)
no single intervention or combination of interventions appeared better than any other to reduce time to PbtO2 correction or to increase magnitude of PbtO2 change; (4) use of
more interventions was associated with a greater time to
PbtO2 normalization; (5) many episodes underwent PbtO2
normalization without interventions, and (6) an increasing the
number of interventions to a maximum of three only had a
favorable effect on ICP or CPP. These data may be used to
guide therapy of compromised PbtO2 and suggest what effect
can be expected.
Methodological Limitations
This study has several potential limitations. First, it is a
retrospective analysis of interventions recorded in a prospective observational database. Second, the sample size of 92
patients is relatively small. However, we examined 600
episodes of compromised PbtO2. Third, this is a single
institution series. Our results, therefore, may lack external
validity and should be considered preliminary. Fourth, we
defined an episode of compromised PbtO2 as 15 minutes to
240 minutes in duration. The lower time limit was arbitrarily
chosen to prevent transient self-limited changes in PbtO2, i.e.,
episodes of coughing, straining, or moving that bedside
clinicians do not routinely treat. Our upper time limit also
was arbitrarily chosen. However, we felt it reasonable to
conclude that if no treatment was initiated within 4 hours, that
care had been deliberately withheld. Fifth, although all specific treatments were prospectively coded in our BOMO
registry, we chose, for the purposes of this study, to examine
treatment classes or interventions (see Methods), thus, any
effects of the specific drug or fluid administered are beyond
the scope of this study. Sixth, we did not control for the
number of times a specific intervention was used to correct a
single episode of compromised PbtO2 or in which order
therapies were given. It was not our goal to describe a precise
recipe to treat compromised PbtO2 because such a recipe is
unlikely to exist. Seventh, the intention behind the clinicians
use of a given intervention was not examined and the use of
a given intervention could have occurred for reasons other
than to correct PbtO2 deficits. Finally, use of T as a primary
outcome may have lead to intrinsic bias because the greater
duration of compromised PbtO2 would inherently allow clinicians more time to administer more interventions. In addition, defining the episode endpoint as normalized PbtO2 (20
mm Hg) may have underestimated any interventions maximal effect on PbtO2. Despite these limitations, the results of
this study from an institution with several years experience
using and studying PbtO2 monitoring by a group of interdisciplinary clinicians provide an in-depth description of what
542
interventions are usually administered to patients with compromised PbtO2 and what results can be expected.
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
available oxygen through increases in FIO2, PEEP, or pulmonary dynamics (prostacyclin in other studies) were the
fourth most common intervention in our study.45 49 The
definitive benefits and, more importantly, risks (oxygen
toxicity) of hyperoxic treatment in TBI, however, remain
unknown.
Combined use of sedation or narcotics osmotherapy
resulted in the most rapid correction of compromised PbtO2
(about 15 minutes) and also appeared to increase PbtO2
and reduce ICP by the greatest margins. It must be noted,
however, that the occurrence of this combination was
exceeding low and therefore no durable conclusion can be
made. Both mannitol and hypertonic saline were included in
the osmotherapy intervention class and are well known to
reduce ICP.50,51 Hypertonic saline in particular has been
shown to improve PbtO2 in TBI patients52 refractive to
mannitol therapy. Efforts to enhance oxygen delivery (DO2)
through transfusion of red blood cells is commonly used
though an improvement in PbtO2 is not always present.53,54 In
addition, there remains controversy on what is the optimal
hemoglobin level for TBI patients.7,55 There is limited data on
how other blood products (e.g., plasma) affect PbtO2.56 A
combination of pressors and fluid boluses may also improve
DO2 although studies in subarachnoid hemorrhage suggest
only induced hypertension has a positive effect on PbtO2.57 In
our study, combined pressors and fluids was associated with
the greatest increase of CPP (14 mm Hg). Although infusions of crystalloids or colloids are commonplace in the ICU
and thought to benefit TBI patients by raising MAP and CPP,
their effect on PbtO2 remains intuitive with limited scientific
evaluation.58 Indeed, some studies suggests PbtO2 monitoring
may lead to overuse of fluids.59 Therapies such as induced
hypothermia and cerebral spinal fluid (CSF) drainage were
used infrequently in our patient cohort and so we cannot
make specific conclusions about their use.
CONCLUSIONS
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Pascual et al.
544
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DISCUSSION
Dr. William C. Chiu (Baltimore, Maryland): Dr. Pascual and his coauthors from the University of Pennsylvania
have presented another study investigating the utility of brain
tissue oxygen-directed management of traumatic brain injury.
Secondary brain injury is associated with episodes of
cerebral ischemia and hypoxia. Most current algorithms for
2011 Lippincott Williams & Wilkins
Pascual et al.
The Journal of TRAUMA Injury, Infection, and Critical Care Volume 70, Number 3, March 2011
546
were being moved or the thought was that this would resolve on
its own and interventions had occurred that were not recorded by
the bedside nurse they waited for the effect to occur.
Who should we monitor brain tissue oxygen on remains
a difficult question. If greater than a third of patients correct
their brain tissue oxygenation on their own, this may be
something very important in the decision tree of what type of
intracranial monitor to insert.
Id like to thank the association, Dr. Jurkovich and Dr.
Cioffi. Thank you.