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- Figaji, Anthony A., et al.
(författare)
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Pressure autoregulation, intracranial pressure, and brain tissue oxygenation in children with severe traumatic brain injury
- 2009
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Ingår i: Journal of Neurosurgery: Pediatrics. - 1933-0715. ; 4:5, s. 420-428
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Tidskriftsartikel (refereegranskat)abstract
- Object. Cerebral pressure autoregulation is an important neuroprotective mechanism that stabilizes cerebral blood flow when blood pressure (BP) changes In this study the authors examined the association between autoregulation and clinical factors. BR. intracranial pressure (ICP), brain tissue oxygen tension (PbtO(2)), and outcome after pediatric severe traumatic brain injury (TBI). In particular we examined how the Status 01: autoregulation influenced the effect of BP changes on ICP and PbtO(2) Methods In this prospective observational study. 52 autoregulation tests were performed in 24 patients with severe. TBI. The patients had a mean age of 6.3 +/- 3.2 years. and a postresuscitation Glasgow Coma Scale score of 6 (range 3-8). All patients underwent continuous ICP and MID, monitoring. and transcranial Doppler ultrasonography was, used to examine the autoregulatory index (ARI) based on blood flow velocity of the middle cerebral artery after increasing mean arterial pressure by 20% of the baseline value Impaired autoregulation was defined as an ARI < 0 4 and intact autoregulation as an ART >= 0 4 The relationships between autoregulation (measured as both a Continuous and dichotomous variable), outcome, and clinical and physiological variables were examined using Multiple logistic regression analysis Results. Autoregulation was impaired (ART < 0 4) in 29% of patients (7 patients). The initial Glasgow Coma Scale score was significantly associated with the ARI (p = 0.02, r = 0.32) but no other clinical factors were associated with autoregulation Status. Baseline values at the time of testing for ICP, PbtO(2), the ratio PbtO(2)/PaO2, mean arterial pressure, and middle cerebral artery blood flow velocity were similar in the patients with impaired or intact autoregulation. There was an inverse relationship between ART (continuous and dichotomous) with a chancle in ICP (continuous ARI, p 0.005, dichotomous ARI, p = 0 02): that is. ICP increased with the BP increase when ARI was low (weak autoregulation) The ART (continuous and dichotomous) was also inversely associated with a change in PbtO(2). (continuous ART. p 0.002. dichotomous ARI, p = 0 02). The PbtO(2) increased when BP was increased in most patients, even when the ARI was relatively high (stronger autoregulation). but the magnitude of this response was still associated with the ART. There was no relationship between the ART and Outcome Conclusion. These data demonstrate the influence of the strength of autoregulation on the response of ICP and MO. to BP changes and the variability of this response between individuals The findings suggest that autoregulation testing may assist clinical decision-making in pediatric severe TBI and help better define optimal BP or cerebral perfusion pressure targets for individual patients. (DOI: 10.3171/2009.6.PEDS096)
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- Figaji, Anthony A., et al.
(författare)
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Transcranial Doppler pulsatility index is not a reliable indicator of intracranial pressure in children with severe traumatic brain injury
- 2009
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Ingår i: Surgical Neurology. - : Elsevier BV. - 0090-3019. ; 72:4, s. 389-394
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Tidskriftsartikel (refereegranskat)abstract
- Background: The TCD-derived PI has been associated with ICP in adult studies but has not been well investigated in children. We examined the relationship between PI and ICP and CPP in children with severe TBI. Methods: Data were prospectively collected from consecutive TCD studies in children with severe TBI undergoing ICP monitoring. Ipsilateral ICP and CPP values were examined with Spearman correlation coefficient (mean values and raw observations), with a GEE, and as binary values (1 and 20 mm Hg, respectively). Results: Thirty-four children underwent 275 TCD studies. There was a weak relationship between mean values of ICP and PI (P = .04, r = 0.36), but not when raw observations (P = .54) or GEE (P = .23) were used. Pulsatility index was 0.76 when ICP was lower than 20 mm Hg and 0.86 when ICP was 20 mm Hg or higher. When PI was 1 or higher, ICP was lower than 20 mm Hg in 62.5% (25 of 40 studies), and when ICP was 20 mm Hg or higher, PI was lower than 1 in 75% (46 of 61 studies). The sensitivity and specificity of a PI threshold of 1 for examining the ICP threshold of 20 mm Hg were 25% and 88%, respectively. The relationship between CPP and PI was stronger (P = .001, r -0.41), but there were too few observations below 50 mm Hg to examine PI at this threshold. Conclusion: The absolute value of the PI is not a reliable noninvasive indicator of ICP in children with severe TBI. Further study is required to examine the relationship between PI and a CPP threshold of 50 mm Hg. (C) 2009 Elsevier Inc. All rights reserved.
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- Sarigul, Buse, et al.
(författare)
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Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury : A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group
- 2023
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Ingår i: Journal of Neurotrauma. - : Mary Ann Liebert. - 0897-7151 .- 1557-9042. ; 40:15-16, s. 1707-1717
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Tidskriftsartikel (refereegranskat)abstract
- Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.
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