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Managing ICP in TBI Patients

One of the central things we do for neuro patients in control their ICP. But, does tight control of ICP improve outcomes?

Is ICP the best thing for us to be optimizing, especially if brain ischemia is what we’re trying to avoid? What about brain tissue oxygenation?

I’ll quickly review the evidence, and you decide.

Lundberg demonstrating ICP measured from an EVD in TBI patients.

Lundberg, N., Troupp, H., Lorin, H. (1965). Continuous Recording of the Ventricular-Fluid Pressure in Patients with Severe Acute Traumatic Brain Injury Journal of Neurosurgery 22(6), 581-590.

Model showing independent effects of ICP and blood pressure on TBI outcomes.

Marmarou, A., Anderson, R., Ward, J., Choi, S., Young, H., Eisenberg, H., Foulkes, M., Marshall, L., Jane, J. (1991). Impact of ICP instability and hypotension on outcome in patients with severe head trauma Journal of Neurosurgery 75(Supplement), S59-S66.

Mortality in TBI over the past 150 years (note the large decrease through the 70s and 80s).

Stein, S., Georgoff, P., Meghan, S., Mizra, K., Sonnad, S. (2010). 150 Years of Treating Severe Traumatic Brain Injury: A Systematic Review of Progress in Mortality Journal of Neurotrauma 27(7), 1343-1353.

BEST-TRIP trial comparing invasive ICP monitoring to clinical exam and CT. No difference in outcomes in severe TBI patients.

Chesnut, R., Temkin, N., Carney, N., Dikmen, S., Rondina, C., Videtta, W., Petroni, G., Lujan, S., Pridgeon, J., Barber, J., Machamer, J., Chaddock, K., Celix, J., Cherner, M., Hendrix, T. (2012). A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury The New England Journal of Medicine 367(26), 2471-2481.

Meta-analysis of invasive ICP studies. Observational studies consistently show a benefit to ICP monitoring.

Shen, L., Wang, Z., Su, Z., Qiu, S., Xu, J., Zhou, Y., Yan, A., Yin, R., Lu, B., Nie, X., Zhao, S., Yan, R. (2016). Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis PLOS ONE 11(12), e0168901.

Original Lancet article discussing secondary injury from ischemia in TBI.

Graham, D., Adams, J. (1971). ISCHÆMIC BRAIN DAMAGE IN FATAL HEAD INJURIES The Lancet 297(7693), 265-266.

First studies to look at outcome in TBI patients using Licox

Santbrink, H., Maas, A., Avezaat, C. (1996). Continuous Monitoring of Partial Pressure of Brain Tissue Oxygen in Patients with Severe Head Injury Neurosurgery 38(1), 21-31.

Valadka, A., Gopinath, S., Contant, C., Uzura, M., Robertson, C. (1998). Relationship of brain tissue PO2 to outcome after severe head injury Critical Care Medicine 26(9), 1576-1581.

BOOST-II trial. Respiratory interventions were able to improve PbO2 in TBI patients, and that group showed an improved outcome, including disability and mortality.

Okonkwo, D., Shutter, L., Moore, C., Temkin, N., Puccio, A., Madden, C., Andaluz, N., Chesnut, R., Bullock, M., Grant, G., McGregor, J., Weaver, M., Jallo, J., LeRoux, P., Moberg, D., Barber, J., Lazaridis, C., Diaz-Arrastia, R. (2017). Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II Critical Care Medicine 45(11), 1907.

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