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transcript
Multimodal monitoring to individualize care in TBI
Critical Care Canada Forum 2017October 4th, 2017
Donald Griesdale MD MPHAssociate ProfessorDepartment of Anesthesiology, Pharmacology & TherapeuticsDivisions of Critical Care Medicine & NeurologyUniversity of British Columbia
I have nothing to disclose
“Severe TBI”
Patient 1 Patient 2 Patient 3
Culture change needs champions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
VGH TBI Protocol
Cerebral Autoregulation
• ICP monitor
• Art line
• ICM+ monitoring
PbO2
• Cerebral oxygenation
• Licox PbO2
Multimodal monitoring
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
2) ICP Catheter
1) Brain oxygen monitor(PbtO2)
Pressure
Measure of blood flow
CerebralAutoregulation
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
ICM+ ® Monitoring Platform
VGH TBI Protocol
Cerebral Autoregulation
• ICP monitor
• Art line
• ICM+ monitoring
PbO2
• Cerebral oxygenation
• Licox PbO2
Multimodal monitoring
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
CBF
CPP
25 50 75 100 125 150 175
25
50
75
100
Zone of autoregulation
CBV
ICP
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
CBF
CPP
25 50 75 100 125 150 175
25
50
75
100
TBI
1. Stroke 2001; 32: 128–322. Acta Anaesthesiol Scand 1996;40:1149
Zone of autoregulation
ICPProblem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
CBF
25 50 75 100 125 150 175
25
50
75
100
ICP
PRx
CPP
CPPOPT
-0.5
0
0.5
1.0
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
ICP
CPP
PRx
0
-0.2
+0.6
PRx
1:30 am
Levo 5 mcg/min
1:32 am
Levo 7 mcg/min
1:35 am
Levo 8 mcg/min
1:37 am
Levo 8 mcg/min
1:37 am
Levo 8 mcg/min
1:40 am
Levo 10 mcg/min
ICPICP ICP
ICPICP
ICP
Autoregulation at the bedside
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions Stock-free-images.net
45yo previously healthy male in MVC
Initial vitals by EHS: SBP 80
SaO2 90%
GCS 3
Prolonged extrication (30 minutes)
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
ICP monitor or not?
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
SjO2 42%
BTF
0
-0.2
+0.6
Optimal CPP 82.5 mmHg
CBF
CPP50 60 70 80 90 100 110 120 130
SjO2 66%
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
VGH TBI Protocol
Cerebral Autoregulation
• ICP monitor
• Art line
• ICM+ monitoring
PbO2
• Cerebral oxygenation
• Licox PbO2
Multimodal monitoring
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Assessment of cerebral blood flow
Insert on the non-injured side
Does not actually measure intracellular hypoxia
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
PbO2 is a measure of CBF under normoxia
35yo male, fell from standing
Initially GCS 3
Left pupil 7 mm and dilated
Right pupil 4mm and reactive
Absent motor function in all 4 extremities
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
CPP
ICP
PRx
PbO2
20
100
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
20
J Neurosurg 2010;113:571
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Phase 2, multicentre, randomized control trial (feasibility study)
ICP / CPP management alone compared to
ICP / CPP + PbO2 (> 20mmHg)
Primary outcome • Percentage of time with PbO2 < 20mmHg
• ICP / CPP group: 0.44
• ICP / CPP + PbO2 group 0.14
• Improved clinical outcomes?
• BOOST - III
BOOST – II Trial
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
1. Individualize patient care decisions
2. “We recommend the continuous assessment & monitoring of ICP and CPP…using a structured protocol”
3. We suggest that monitoring and assessment of autoregulation may be useful in broad targeting of CPP management
4. We recommend monitoring brain oxygen in patients with or at risk of cerebral ischemia and/or hypoxia
5. “It is difficult to demonstrate that any single monitor or combination of monitors has a positive effect on outcome, since outcome is influenced by the therapeutic plan driven by monitoring, not by monitoring itself”
ICM published online 2014
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Total Cohort
(n=113)
Age in years, mean (SD) 39 (2)
Male gender, n(%) 87 (77)
Admission hypotension, n(%) 40 (35)
Admission hypoxemia, n(%) 26 (23)
Glasgow Coma Scale median motor score (IQR) 3 (1 – 4)
One pupil non-reactive, n(%) 33 (29)
Mechanism of injury, n(%)
Motor vehicle or motor cycle accident 34 (30)
Accidental fall 45 (40)
Pedestrian or cyclist struck 24 (21)
Other 10 (9)
Rotterdam score, median (IQR) 3 (3 – 4)
SD = standard deviation; IQR = interquartile range
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
37%
60%
TBI protocols that reduce detrimental variability are important
Protocols need to allow changes in management depending on the underlying cerebral physiology
Autoregulation monitoring using PRx allows titration of cerebral perfusion pressure
PbO2 monitoring allows optimization of cerebral oxygen delivery
Evidence for multimodal monitoring is still limited
Implementation of a consolidated TBI program requires multidisciplinary champions and culture change
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
23 year old female, professional freestyle skier
Undergoes a fall on the half pipe at Whistler (April 5th)
Intubated on scene and transferred via Helicopter to VGH
Initial examination: E1, Vt, M2
MRI = Grade 3 Diffuse Axonal Injury (brainstem involvement)
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
ConclusionsCRASH & IMPACT TBI Prognosis Predictor
6 month mortality = 54%6 month unfavourable outcome = 81%
Problem: generalized interventions
Multimodal neuromonitoring
Autoregulation monitoring: PRx
PRx physiology
PRx case example
PRx: what is the evidence?
PbO2 monitoring
PbO2 is a measure of CBF
PbO2 case example
PbO2: what is the evidence?
Multimodal monitoring consensus
Our data: the first year
Conclusions
Our patients
All of the nurses and physicians of the intensive care unit
Dr. Mypinder Sekhon (neurointensivist)
Ms. Denise Foster
Drs. Peter Gooderham & Brian Toyota (neurosurgery)
Neurosurgical residents
Dr. George Isac (Medical director, intensive care)
Jackson Lam (Patient Services Manager, intensive care)
Dr. Dean Chittock (Senior Medical Director)
Vivian Eliopoulos (COO, VCH)
Thank You