multimodal monitoring to individualize care in tbi · 2019. 9. 27. · multimodal monitoring to...

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