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

Celeste Dias
Celeste Dias
, 
Alexandre de Castro
Alexandre de Castro
, 
Rita Gaio
Rita Gaio
, 
Ricardo Silva
Ricardo Silva
, 
Eduarda Pereira
Eduarda Pereira
 e 
Elisabete Monteiro
Elisabete Monteiro
   | 08 mag 2023
The Journal of Critical Care Medicine's Cover Image
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Article Category: Research Article
Pubblicato online: 08 mag 2023
Pagine: 97 - 105
Ricevuto: 11 ago 2022
Accettato: 31 gen 2023
DOI: https://doi.org/10.2478/jccm-2023-0009
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© 2023 Celeste Dias et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

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 Patients Total 92
Multiple Trauma 45 (49%)
Thoracic Trauma 19 (21%)
Age (Years) 53 ± 21
Gender Male 79 (86%)
Female 13 (14%)
GCS at admission 7 (IQR 5)
APACHE II 19 ± 6
Apache II mortality (%) 33 ± 17
CT Marshall Classification 3 (IQR 2)
Monitoring and Management Data
FiO2 0.5 ± 0.13
PFratio 305 ± 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
Compliance 43 ± 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
PRx 0.03 ± 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
Mortality 14 (15.2%)
GOS at 3 months 3 (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.

Variables FIXED EFFECTS RANDOM EFFECT
Coefficient St Error p-value St deviation
Model for the time-effect on PFratio
Intercept 436.42 17.63 <0.001 59.25
Time (days) −27.12 4.56 <0.001
Days2 2.175 0.48 <0.001
Female 99.28 23.39 <0.001
PRx −49.99 15.68 0.002
Ppl-Peep −5.34 0.97 <0.001
Model for the time-effect of outcome on CPP-CPPopt
Intercept −2.37 1.58 0.133 2.95
Dead −0.79 1.72 0.647
Time (days) −0.56 0.28 0.048
Time*Dead 1.10 0.31 <0.001
Model for the time-effect of outcome on Driving Pressure
Intercept 14.76 1.10 <0.001 2.85
Dead −0.43 1.20 0.718
Time (days) 0.68 0.15 <0.001
Time*Dead −0.34 0.17 0.041
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