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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
2008 were considered for study. Patients were retrospectively 80 100 mL/h), (7) anticonvulsant prophylaxis with phenyt-
identified from a prospective observational database, the Brain oin for 1 week or longer if seizures occurred, and (8) packed
Oxygen Monitoring Outcomes (BOMO) registry, which has red blood cell transfusion if their Hgb was 7.
Institutional Review Board approval. Patients with gunshot
wounds or other penetrating cranial injuries, ongoing blood Management of Intracranial Hypertension
loss, or whose postresuscitation systolic blood pressure was If ICP remained persistently elevated (20 mm Hg
90 mm Hg and arterial oxygen saturation (SaO2) 93% 10 min) despite baseline initial measures, osmotherapy was
were excluded from analysis. Patients in whom pupils were administered using repeated boluses of mannitol (1 gm/kg,
bilaterally fixed and dilated or were brain dead or imminently 25% solution) provided that serum osmolar gap 20. Second
dead on admission also were excluded. tier therapies for refractory intracranial hypertension (20
mm Hg 15 minutes in a 1-hour period despite therapy)
Brain Intraparenchymal Monitors included optimized hyperventilation (PaCO2 30 35 mm Hg),
ICP, brain temperature, and brain tissue oxygen decompressive craniectomy, or pharmacological coma (with
(PbtO2) were continuously monitored using a commercially propofol or pentobarbital). Induced hypothermia and hyper-
available intracranial device (LICOX; Integra LifeSciences, tonic saline for ICP control were used to manage ICP in the
Plainsboro, NJ). All three intracranial monitors were inserted patients included during the last 2.5 years of this study.
at the bedside through the same burr-hole into the frontal lobe
and secured with a triple-lumen bolt. The PbtO2 monitor was Evaluation of Brain Oxygen Treatment
placed into white matter that appeared normal on the admis- During the study period patients received cause directed
sion head CT and on the side of maximal pathology. Brain therapy at the intensivists discretion to maintain PbtO2 20
tissue oxygenation data were acquired after a stabilization mm Hg according to our local protocol (Fig. 1). The BOMO
period of 2 hours after probe insertion. Probe function and registry records and codes every event noted by a bedside nurse
location were confirmed by an appropriate increase in PbtO2 in the chart and also records hemodynamics, cerebral parame-
after an hyperoxic FIO2 challenge (FIO2 100%)17 and a ters, and other nursing entries every 10 minutes to 20 minutes.
head CT scan to verify correct placement of the various There was 8000 hours of PbtO2 monitoring in eligible patients
monitors, e.g., not in a contusion or infarct. CPP was calcu- available for review. Episodes where PbtO2 was 20 mm Hg
lated from measured parameters (CPP mean arterial pres- for 15 minutes but 4 hours were abstracted. There have been
sure [MAP] ICP). All intracranial monitors were removed several important described thresholds for PbtO2 that identify
when ICP was normal for 24 hours without specific treatment when cell death or ischemia may be evident and at what level to
other than sedation for ventilation, when the patient was able treat. We chose a PbtO2 threshold of 20 mm Hg because this
to follow commands or when the patient was brain dead. corresponds to the minimal necessary oxygen tension for mito-
chondria, where the majority of cellular oxygen metabolism
Physiologic Monitors occurs to maintain aerobic metabolism.18 In addition, it is the
Heart rate, arterial line blood pressures, and arterial oxy- threshold being used in a current NIH-funded trial to prospec-
gen saturations (SaO2) were monitored continuously (Compo- tively examine PbtO2 in TBI. We chose a 15-minute minimum
nent Monitoring System M1046-9090C: Hewlett Packard, time window to eliminate incidental, self-limited episodes of
Andover, MA). The MAP was derived from arterial lines with compromised PbtO2 and to allow time for a 2-minute oxygen
transducers leveled at the phlebostatic axis. Central venous challenge as required by protocol to test monitor function. Thus,
pressures and pulmonary artery pressures were followed in patients this brief FIO2 challenge was not considered therapeutic and so
with intravascular depletion or cardiopulmonary compromise. was excluded from analysis. We chose a 4-hour maximum to
avoid inclusion of patients who no longer were receiving active
General Clinical Management of TBI treatment for PbtO2 deficits by bedside clinicians. Also this was
Trauma surgeons resuscitated all patients according to done to avoid the inclusion of episodes where clinicians were
Advanced Trauma Life Support (ATLS) protocols (American aggressively using all possible interventions in the setting of a
College of Surgeons Committee on Trauma: Advanced resistant compromised PbtO2.
Trauma Life Support Course for Doctors. Chicago: American We consulted seasoned intensivists, neurologists, trauma
College of Surgeons, 1997). Patients then were managed surgeons, and neurosurgeons who cared for brain injured pa-
according to a local algorithm based on the BTF Guidelines tients to achieve a consensus of what therapies were considered
for Severe TBI5 in the Neurosurgical Intensive Care Unit useful to correct PbtO2 deficits. Eleven interventions were se-
or the Surgical and Trauma Intensive Care Unit. This lected by the panel and thereafter identified from the coded
included (1) early identification and evacuation of traumatic treatments in the BOMO registry. They are presented in Table 1.
space-occupying intracranial hematomas, (2) intubation and During each episode of PbtO2 compromise, various reg-
ventilation with low-volume pressure-limited ventilation to istry parameters were recorded before the decrease and on
maintain PaCO2 between 30 and 40 mm Hg and SaO2 93%, (3) correction of the PbtO2 deficit (20 mm Hg). Collected param-
sedation using propofol during the first 24 hours followed by eters included patient hemodynamics (systolic blood pressure,
sedation and analgesia using lorazepam, morphine, or fenta- MAP, and heart rate [HR]), ventilation parameters (positive end
nyl, (4) bedrest with head elevation of 30 degrees, (5) expiratory pressure [PEEP], PaO2 or PaCO2, SaO2, and FIO2), and
normothermia 35C to 37C, (6) euvolemia using a base- cerebral parameters (ICP, CPP, and PbtO2). All coded interven-
line crystalloid infusion (0.9% normal saline, 20 mEq/L KCl; tions thought to potentially affect PbtO2 (Table 1) that were
Figure 1. Institutional algorithm for severe TBI management. ET tube, endotracheal tube; ABG, arterial blood gas; SjvO2, jug-
ular venous bulb oxygenation; Hgb, hemoglobin; PaCO2, partial carbon dioxide tension of blood.
administered during this time period were collected. Basic de- routinely and entered into the BOMO registry by an outpatient
mographics (age, sex, and race) and illness scores (Injury Se- nurse.
verity Score, Acute Physiology and Chronic Health Evaluation,
Abbreviated Injury Scale, and Glasgow Coma Score [GCS]) Analysis and Statistics
were collected for each patient. Comparison between treatments, combination of treat-
ments, or no treatment was evaluated with analysis of variance
Outcome Assessment and post hoc analysis (Tukey) to examine their effect on time to
Discharge disposition was recorded for all patients. In normalization of PbtO2 (T), the magnitude of PbtO2 change
patients who survived past discharge, a functional outpatient (PbtO2) as well as on ICP and CPP. To analyze which
evaluation interview 3- to 6-month postdischarge was obtained treatment or combination of treatments, if any, was superior
using the Glasgow Outcome Score-extended (GOS-e)19 and linear regression analysis was used. SPSS software (SPSS,
modified Rankin Scale (mRS)20 scores. These data are acquired Chicago, IL) was used for analysis. Continuous data are pre-
interventions increased. The number of patients treated with magnitude of PbtO2 (PbtO2) increase averaged 9.5 mm
more than two interventions was small; however, T was Hg 9.9 mm Hg and was not associated with number of
greater in patients that had more than two interventions than interventions used (p 0.53). The average (SD) T when no
those with one or two interventions (p 0.05; Table 5). The intervention was administered was 0.84 hours 0.63 hours.
TABLE 5. Comparison Between Number of Interventions as What Interventions Were Used to Correct
Described in Table 4 Compromised PbtO2?
No. of Intervention(s) p Only one or two interventions were used to correct
1 vs. 3 0.00
compromised PbtO2 in the majority of episodes and so
1 vs. 4 0.01
subsequent analyses were limited to these groups. The com-
1 vs. 5 0.01
monest strategies used to treat compromised PbtO2 are sum-
2 vs. 5 0.01
marized in Table 6. The most common single interventions
2 vs. 4 0.03
were sedation or analgesia (N 60), pressors (N 51),
2 vs. 3 0.03
increase in FIO2/PEEP (N 24), and patient repositioning
5 vs. 3 0.07
(N 27; Table 7). Of these, pressors were associated with
5 vs. 4 0.24
the lowest T (fastest correction). Single interventions asso-
2 vs. 1 0.33
ciated with the greatest PbtO2 were osmotherapy (14 mm
4 vs. 3 0.38
Hg 11 mm Hg) and red cell transfusion (27 mm Hg) but the
frequency of these interventions was low. No one interven-
Tukey posthoc analysis comparing the number of interventions used on time to tion appeared superior using simple linear regression analysis
PbtO2 correction (T). One or two interventions always correct PbtO2 significantly
faster than 3, 4, or 5 interventions. There is no significance difference when using 1 or (R2 0.2; p 0.05). One hundred one episodes were treated
2 interventions to correct PbtO2. with two interventions; the most common was sedation or
Therapeutic Interventions for Compromised available oxygen through increases in FIO2, PEEP, or pul-
PbtO2 monary dynamics (prostacyclin in other studies) were the
Although clinical series suggest that there may be a fourth most common intervention in our study.45 49 The
benefit to PbtO2-based care, it remains unclear what consti- definitive benefits and, more importantly, risks (oxygen
tutes this care as the specific therapies for compromised toxicity) of hyperoxic treatment in TBI, however, remain
PbtO2 are only beginning to be defined. In this study, we unknown.
describe what interventions may be used and their expected Combined use of sedation or narcotics osmotherapy
efficacy when PbtO2 is compromised. Our registry (BOMO) resulted in the most rapid correction of compromised PbtO2
codes 80 clinician interventions in the ICU. This includes (about 15 minutes) and also appeared to increase PbtO2
specific items such as mouthcare, proning, abdominal and reduce ICP by the greatest margins. It must be noted,
operation, or patient reposition that are recorded in the however, that the occurrence of this combination was
nursing record at time intervals as short as 10 minutes to 20 exceeding low and therefore no durable conclusion can be
minutes. We conducted a detailed evaluation of these coded made. Both mannitol and hypertonic saline were included in
treatments and, with expert consensus, grouped them in 11 the osmotherapy intervention class and are well known to
classes of interventions (Table 6). Although many of these reduce ICP.50,51 Hypertonic saline in particular has been
interventions are used by clinicians caring for TBI patients shown to improve PbtO2 in TBI patients52 refractive to
worldwide and often in the setting of reduced ICP or MAP, mannitol therapy. Efforts to enhance oxygen delivery (DO2)
there is limited study of how these interventions affect com- through transfusion of red blood cells is commonly used
promised PbtO2. We thus sought to first delineate what though an improvement in PbtO2 is not always present.53,54 In
interventions were used most frequently in TBI patients with addition, there remains controversy on what is the optimal
compromised PbtO2. Greater than one third of such episodes hemoglobin level for TBI patients.7,55 There is limited data on
PbtO2 resolved without any apparent intervention. These how other blood products (e.g., plasma) affect PbtO2.56 A
episodes may simply have been self-limited and thus raise the combination of pressors and fluid boluses may also improve
question on how to identify reductions in PbtO2 that do not DO2 although studies in subarachnoid hemorrhage suggest
require treatment. However, they also may represent an only induced hypertension has a positive effect on PbtO2.57 In
episode where some other trigger (e.g., low ICP, high CPP) our study, combined pressors and fluids was associated with
resulted in treatment initiation before the identified decrease the greatest increase of CPP (14 mm Hg). Although infu-
in PbtO2 and the effect of these intervention(s) eventually sions of crystalloids or colloids are commonplace in the ICU
also normalized PbtO2. Yet, when evaluating the effect of any and thought to benefit TBI patients by raising MAP and CPP,
intervention or combination of interventions on ICP and CPP their effect on PbtO2 remains intuitive with limited scientific
effects were at most modest. 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
Specific Interventions for Compromised used infrequently in our patient cohort and so we cannot
PbtO2Alone or in Combination? make specific conclusions about their use.
The use of a single intervention for compromised PbtO2
was the most frequent strategy, and among these, narcotic
analgesics or sedatives, often used in TBI to control ICP,39 42 CONCLUSIONS
was most common (Table 4). Pressors were the next most Accumulating evidence suggests that PbtO2-directed
frequent therapy. These agents are also frequently used in therapy may provide an advantage over ICP or CPP only
TBI care, but which specific agent (phenylephrine, dopamine, guided management. However, there is little data on what
norepinephrine) is preferable is not well defined.43,44 In ad- interventions should be included in such a PbtO2 treatment
dition, overuse of pressors may exacerbate lung function.5 Of bundle. Bundled treatments have improved the care of
interest, we observed that, among the most popular treat- critically ill patients in other fields such as sepsis.60 However,
ments, pressors appeared to be associated with the shortest the individual components may not demonstrate this advan-
time interval for PbtO2 correction (T). However, this may tage in the absence of the remaining components and the
mean pressors were only used late or after other interventions environment where they are administered. This study does
failed. Patient repositioning was the third most common not provide a recipe for the best ICU intervention or combi-
intervention we observed and often increased PbtO2 by 10 nation of interventions to treat compromised PbtO2 in TBI
mm Hg or more. Head and neck repositioning, elevating the patients. However, we have learnt several important points.
head of the bed, turning a patient or loosening a cervical First, clinicians tend to use a small number of treatments and
collar are common practice in TBI patients, but the direct prefer to use combinations of at most one or two to correct
effects and durability of these interventions may be more compromised PbtO2. Second, the most common interventions
opinion than fact. These maneuvers, however, are recom- may improve ICP or CPP but may not always increase PbtO2.
mended as good clinical care and are likely to benefit the Third, use of more treatments does not mean more rapid
patient without significant risk. It is conceivable that we correction of compromised PbtO2. This is particularly
underestimated their use and effect because they most likely important because some interventions to correct intracra-
were applied as part of general care rather than when a nial abnormalities are known to exacerbate injury in other
specific monitored abnormality occurred. Efforts to increase organ systems of critically ill patients. Finally, some PbtO2
compromises may correct on their own and how to identify 20. van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn
such self-resolving deficits remains unclear. In summary, this J. Interobserver agreement for the assessment of handicap in stroke
patients. Stroke. 1988;19:604 607.
study provides an insight in what interventions are most used 21. Marshall LF, Smith RW, Shapiro HM. The outcome with aggressive
in a center familiar with PbtO2-directed TBI care. The effects treatment in severe head injuries. Part II: acute and chronic barbiturate
of these popular interventions will need further evaluation administration in the management of head injury. J Neurosurg. 1979;
and comparisons to establish their efficacy, safety, timing, 50:26 30.
22. Marshall LF, Smith RW, Shapiro HM. The outcome with aggressive
and sequencing for future severe TBI management. treatment in severe head injuries. Part I: the significance of intracranial
pressure monitoring. J Neurosurg. 1979;50:20 25.
23. Miller JD, Butterworth JF, Gudeman SK, et al. Further experience in the
REFERENCES management of severe head injury. J Neurosurg. 1981;54:289 299.
1. Murray GD, Teasdale GM, Braakman R, et al. The European Brain 24. Narayan RK, Kishore PR, Becker DP, et al. Intracranial pressure: to
Injury Consortium survey of head injuries. Acta Neurochir (Wien). monitor or not to monitor? A review of our experience with severe head
1999;141:223236. injury. J Neurosurg. 1982;56:650 659.
2. Menon DK, Coles JP, Gupta AK, et al. Diffusion limited oxygen 25. Cremer OL, van Dijk GW, van Wensen E, et al. Effect of intracranial
delivery following head injury. Crit Care Med. 2004;32:1384 1390. pressure monitoring and targeted intensive care on functional outcome
3. Vespa P, Bergsneider M, Hattori N, et al. Metabolic crisis without brain after severe head injury. Crit Care Med. 2005;33:22072213.
ischemia is common after traumatic brain injury: a combined microdi- 26. Shafi S, Diaz-Arrastia R, Madden C, Gentilello L. Intracranial pressure
alysis and positron emission tomography study. J Cereb Blood Flow monitoring in brain-injured patients is associated with worsening of
Metab. 2005;25:763774. survival. J Trauma. 2008;64:335340.
4. Ross DT, Graham DI, Adams JH. Selective loss of neurons from the 27. Stein SC, Georgoff P, Meghan S, Mirza KL, El Falaky OM. Relationship
thalamic reticular nucleus following severe human head injury. of aggressive monitoring and treatment to improved outcomes in severe
J Neurotrauma. 1993;10:151165. traumatic brain injury. J Neurosurg. 2010;112:11051112.
5. Brain Trauma Foundation; American Association of Neurological Sur- 28. Le Roux PD, Newell DW, Lam AM, Grady MS, Winn HR. Cerebral
geons; Congress of Neurological Surgeons. Guidelines for the management arteriovenous oxygen difference: a predictor of cerebral infarction and
of severe traumatic brain injury. J Neurotrauma. 2007;24(suppl 1):S1 outcome in patients with severe head injury. J Neurosurg. 1997;87:1 8.
S106. 29. Stein SC, Graham DI, Chen XH, Smith DH. Association between
6. Brain Trauma Foundation; American Association of Neurological Sur- intravascular microthrombosis and cerebral ischemia in traumatic brain
geons; Congress of Neurological Surgeons; Joint Section on Neu- injury. Neurosurgery. 2004;54:687 691; discussion 691.
rotrauma and Critical Care, AANS/CNS, Carney NA, Ghajar J. Guide- 30. van Santbrink H, vd Brink WA, Steyerberg EW, Carmona Suazo JA,
lines for the management of severe traumatic brain injury. Introduction. Avezaat CJ, Maas AI. Brain tissue oxygen response in severe traumatic
J Neurotrauma. 2007;24(suppl 1):S1S2. brain injury. Acta Neurochir (Wien). 2003;145:429 438; discussion
7. Chang JJ, Youn TS, Benson D, et al. Physiologic and functional 438.
outcome correlates of brain tissue hypoxia in traumatic brain injury. Crit 31. Stiefel MF, Udoetuk JD, Spiotta AM, et al. Conventional neurocritical
Care Med. 2009;37:283290. care and cerebral oxygenation after traumatic brain injury. J Neurosurg.
8. Gopinath SP, Robertson CS, Contant CF, et al. Jugular venous desatu- 2006;105:568 575.
ration and outcome after head injury. J Neurol Neurosurg Psychiatry. 32. Longhi L, Valeriani V, Rossi S, De Marchi M, Egidi M, Stocchetti N.
1994;57:717723. Effects of hyperoxia on brain tissue oxygen tension in cerebral focal
9. Maloney-Wilensky E, Gracias V, Itkin A, et al. Brain tissue oxygen and lesions. Acta Neurochir Suppl. 2002;81:315317.
outcome after severe traumatic brain injury: a systematic review. Crit 33. Bardt TF, Unterberg AW, Hartl R, Kiening KL, Schneider GH, Lanksch
Care Med. 2009;37:20572063. WR. Monitoring of brain tissue PO2 in traumatic brain injury: effect of
10. van den Brink WA, van Santbrink H, Steyerberg EW, et al. Brain cerebral hypoxia on outcome. Acta Neurochir Suppl. 1998;71:153156.
oxygen tension in severe head injury. Neurosurgery. 2000;46:868 876; 34. Valadka AB, Gopinath SP, Contant CF, Uzura M, Robertson CS.
discussion 876 868. Relationship of brain tissue PO2 to outcome after severe head injury.
11. Martini RP, Deem S, Yanez ND, et al. Management guided by brain Crit Care Med. 1998;26:1576 1581.
tissue oxygen monitoring and outcome following severe traumatic brain 35. Brain Trauma Foundation; American Association of Neurological Sur-
injury. J Neurosurg. 2009;111:644 649. geons; Congress of Neurological Surgeons; Joint Section on Neu-
12. Meixensberger J, Jaeger M, Vath A, Dings J, Kunze E, Roosen K. Brain rotrauma and Critical Care, AANS/CNS; Bratton SL, Chestnut RM,
tissue oxygen guided treatment supplementing ICP/CPP therapy after trau- Ghajar J, et al. Guidelines for the management of severe traumatic brain
matic brain injury. J Neurol Neurosurg Psychiatry. 2003;74:760 764. injury. X. Brain oxygen monitoring and thresholds. J Neurotrauma.
13. Narotam PK, Morrison JF, Nathoo N. Brain tissue oxygen monitoring in 2007;24(suppl 1):S65S70.
traumatic brain injury and major trauma: outcome analysis of a brain 36. Murray GD, Butcher I, McHugh GS, et al. Multivariable prognostic
tissue oxygen-directed therapy. J Neurosurg. 2009;111:672 682. analysis in traumatic brain injury: results from the IMPACT study.
14. Spiotta AM, Stiefel MF, Gracias VH, et al. Brain tissue oxygen-directed J Neurotrauma. 2007;24:329 337.
management and outcome in patients with severe traumatic brain injury. 37. Nangunoori RM-WE, Stiefel M, Park S, et al. Brain Tissue Oxygen
J Neurosurg. 2010;113:571580. Based Therapy and Outcome After Severe Traumatic Brain Injury: A
15. Stiefel MF, Spiotta A, Gracias VH, et al. Reduced mortality rate in Systematic Literature Review. Las Vegas, Nevada: National Neu-
patients with severe traumatic brain injury treated with brain tissue rotrauma Annual Meeting; 2010.
oxygen monitoring. J Neurosurg. 2005;103:805 811. 38. Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS.
16. Adamides AA, Cooper DJ, Rosenfeldt FL, et al. Focal cerebral oxygen- Adult respiratory distress syndrome: a complication of induced hyper-
ation and neurological outcome with or without brain tissue oxygen- tension after severe head injury. J Neurosurg. 2001;95:560 568.
guided therapy in patients with traumatic brain injury. Acta Neurochir 39. Gremmelt A, Braun U. Analgesia and sedation in patients with head-
(Wien). 2009;151:1399 1409. brain trauma. Anaesthesist. 1995;44(suppl 3):S559 S565.
17. Wilensky EM, Bloom S, Leichter D, et al. Brain tissue oxygen practice 40. Jagannathan J, Okonkwo DO, Yeoh HK, et al. Long-term outcomes and
guidelines using the LICOX CMP monitoring system. J Neurosci Nurs. prognostic factors in pediatric patients with severe traumatic brain injury
2005;37:278 288. and elevated intracranial pressure. J Neurosurg Pediatr. 2008;2:240 249.
18. Siesjo BK, Siesjo P. Mechanisms of secondary brain injury. Eur J 41. Sabsovich I, Rehman Z, Yunen J, Coritsidis G. Propofol infusion
Anaesthesiol. 1996;13:247268. syndrome: a case of increasing morbidity with traumatic brain injury.
19. Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Am J Crit Care. 2007;16:82 85.
Glasgow Outcome Scale and the extended Glasgow Outcome Scale: 42. Schmittner MD, Vajkoczy SL, Horn P, et al. Effects of fentanyl and
guidelines for their use. J Neurotrauma. 1998;15:573585. S()-ketamine on cerebral hemodynamics, gastrointestinal motility, and
need of vasopressors in patients with intracranial pathologies: a pilot neurologic monitoring use intracranial and cerebral perfusion
study. J Neurosurg Anesthesiol. 2007;19:257262.
pressure monitoring-based therapy.
43. Pfister D, Strebel SP, Steiner LA. Effects of catecholamines on cerebral
blood vessels in patients with traumatic brain injury. Eur J Anaesthesiol Previous work from this group has suggested that brain
Suppl. 2008;42:98 103. tissue oxygen monitoring is safe and that low brain tissue
44. Myburgh JA. Driving cerebral perfusion pressure with pressors: how, oxygen can be corrected, and may be associated with reduced
which, when? Crit Care Resusc. 2005;7:200 205. mortality.
45. Tolias CM, Reinert M, Seiler R, Gilman C, Scharf A, Bullock MR.
Normobaric hyperoxia-induced improvement in cerebral metabolism This study has confirmed their previous findings that
and reduction in intracranial pressure in patients with severe head injury: common interventions employed for TBI management suc-
a prospective historical cohort-matched study. J Neurosurg. 2004;101: cessfully improve episodes of low brain tissue oxygen and
435 444. that just one or two interventions normalize brain tissue
46. Menzel M, Doppenberg EM, Zauner A, Soukup J, Reinert MM, Bullock
R. Increased inspired oxygen concentration as a factor in improved brain
oxygen in the majority of patients.
tissue oxygenation and tissue lactate levels after severe human head There are two particular study results that I found most
injury. J Neurosurg. 1999;91:110. intriguing: one, the combination of sedation and osmotherapy
47. Menzel M, Doppenberg EM, Zauner A, et al. Cerebral oxygenation in resulted in the most rapid correction of compromised brain
patients after severe head injury: monitoring and effects of arterial tissue oxygen and reduction of ICP.
hyperoxia on cerebral blood flow, metabolism and intracranial pressure.
J Neurosurg Anesthesiol. 1999;11:240 251. Change in CPP with this combination was not so
48. Diringer MN. Hyperoxia: good or bad for the injured brain? Curr Opin impressive. Instead, the combination of pressors and fluids
Crit Care. 2008;14:167171. resulted in the greatest increase in CPP but the change in
49. Stiefel MF, Zaghloul KA, Bloom S, Gracias VH, LeRoux PD. Improved brain tissue oxygen and ICP were only mild.
cerebral oxygenation after high-dose inhaled aerosolized prostacyclin ther-
apy for acute lung injury: a case report. J Trauma. 2007;63:11551158.
These findings suggest that interventions that reduce
50. Wakai A, Roberts I, Schierhout G. Mannitol for acute traumatic brain ICP also improve brain tissue oxygen but not CPP. It also
injury. Cochrane Database Syst Rev. 2007;1:CD001049. reminds us that interventions that improve CPP may simply
51. Ogden AT, Mayer SA, Connolly ES Jr. Hyperosmolar agents in neuro- improve mean arterial pressure without improving ICP.
surgical practice: the evolving role of hypertonic saline. Neurosurgery.
Two, the proportion of reduced brain tissue oxygen
2005;57:207215; discussion 207215.
52. Pascual JL, Maloney-Wilensky E, Reilly PM, et al. Resuscitation of that normalized without treatment was 45 percent. Further-
hypotensive head-injured patients: is hypertonic saline the answer? Am more, normalization of brain tissue oxygen was more rapid
Surg. 2008;74:253259. in those patients without intervention compared to those
53. Smith MJ, Stiefel MF, Magge S, et al. Packed red blood cell transfusion with intervention.
increases local cerebral oxygenation. Crit Care Med. 2005;33:1104 1108.
54. Zygun DA, Nortje J, Hutchinson PJ, Timofeev I, Menon DK, Gupta AK. Patients requiring an incremental increase in number
The effect of red blood cell transfusion on cerebral oxygenation and of interventions required an associated increased time for
metabolism after severe traumatic brain injury. Crit Care Med. 2009; normalization of brain tissue oxygen. This finding reminds
37:1074 1078. us of the difficulty in establishing causality in retrospective
55. Fluckiger C, Bechir M, Brenni M, et al. Increasing hematocrit above
28% during early resuscitative phase is not associated with decreased
research.
mortality following severe traumatic brain injury. Acta Neurochir Patients requiring five interventions to normalize brain
(Wien). 2010;152:627 636. tissue oxygen may have had more resistant hypoxia. There-
56. Senft C, Schuster T, Forster MT, Seifert V, Gerlach R. Management and fore, it is probably unfair to conclude that increasing the
outcome of patients with acute traumatic subdural hematomas and number of interventions resulted in worsening the time to
pre-injury oral anticoagulation therapy. Neurol Res. 2009;31:1012
1018. brain tissue oxygen correction.
57. Muench E, Horn P, Bauhuf C, et al. Effects of hypervolemia and I just have two questions for Dr. Pascual, one, in the
hypertension on regional cerebral blood flow, intracranial pressure, and group of 280 instances of low brain tissue oxygen with no
brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. intervention the time to normalization was a mean of 50
2007;35:1844 1851; quiz 1852.
58. Schmoker JD, Shackford SR, Wald SL, Pietropaoli JA. An analysis of
minutes. Please speculate on the justification for no interven-
the relationship between fluid and sodium administration and intracra- tions during 50 minutes of brain tissue hypoxia.
nial pressure after head injury. J Trauma. 1992;33:476 481. And, two, based upon your institutions experience,
59. Fletcher JJ, Bergman K, Blostein PA, Kramer AH. Fluid balance, which patients, then, do you recommend should have brain
complications, and brain tissue oxygen tension monitoring following
tissue oxygen-directed management?
severe traumatic brain injury. Neurocrit Care. 2010;13:4756.
60. Rivers E, Nguyen B, Havstad S, et al; Early Goal-Directed Therapy Dr. Jose L. Pascual (Philadelphia, Pennsylvania):
Collaborative Group. Early goal-directed therapy in the treatment of Thank you, Dr. Chiu for your insightful comments.
severe sepsis and septic shock. N Engl J Med. 2001;345:1368 1377. I have to say that while interesting, the sedation/narcotics
plus osmotherapy combination is difficult to interpret in the
setting of such few occurrences in the whole sample size.
DISCUSSION To address the specific questions, we also were won-
Dr. William C. Chiu (Baltimore, Maryland): Dr. Pas- dering two questions: how is it that no intervention for a mean
cual and his coauthors from the University of Pennsylvania time of 50 minutes results still in correction of brain tissue
have presented another study investigating the utility of brain oxygen?
tissue oxygen-directed management of traumatic brain injury. We speculated a few answers. One, that brain tissue
Secondary brain injury is associated with episodes of oxygen in some cases does correct on its own without any
cerebral ischemia and hypoxia. Most current algorithms for intervention.
Another is that maybe some interventions occurred were being moved or the thought was that this would resolve on
before the drop in brain tissue oxygen because ICP or CPP its own and interventions had occurred that were not recorded by
took a poor turn. ICP was increased; CPP was decreased the bedside nurse they waited for the effect to occur.
and interventions were performed just before the drop in Who should we monitor brain tissue oxygen on remains
brain tissue oxygen and then affected brain oxygen. a difficult question. If greater than a third of patients correct
Also, perhaps we didnt capture interventions such as a their brain tissue oxygenation on their own, this may be
bedside nurse repositioning the patient and not recording it in something very important in the decision tree of what type of
the record. intracranial monitor to insert.
Why would people not treat a patient with 50 minutes of Id like to thank the association, Dr. Jurkovich and Dr.
brain tissue decreases in oxygenation? Perhaps because they Cioffi. Thank you.