Multimodal Monitoring in Head Injured Patients - Management of CPP: Detection and Treatment of optimal CPP

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Multimodal Monitoring in Head Injured Patients
-Management of CPPDetection and Treatment of
optimal CPP

• Jürgen Meixensberger
• Department of Neurosurgery

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CPP index of input pressure determining CBF and
perfusion

• 1. Why?
• 2. Critical Border ?
• 3. Time Course ?
• 4. Individual
• optimized CPP ?
• 5. Therapy

Effect of reduced CBF
ml/100g/min
Edema, Lactate
Ischemia
Loss of electric activity
Penumbra
Loss of Na/K Pump, ATP
Infarction
Cell death
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Risk to secondary ischemic brain damage

• Traumatic brain injury
• diffuse
• focal, multiple
• Subarachnoid Hemorrhage
• Vasospasm
• Ischemic Stroke
• Penumbra

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Guideline German Society of Neurosurgery Traumatic
Brain Injury in Adults

CPP Adequate cerebral perfusion pressure is
necessary to provide a sufficient cerebral blood
flow. The question, whether to treat increased
ICP or maintainance of CPP as first treatment
goal, is still controversial in the literature.

AWMF Leitlinien Register Nr. 008/001
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Cerebral Perfusion Pressure CPP

• Definition
• Cerebral Perfusion Pressure is a surrogate of
  cerebral blood flow CBF.
• CBF CPP (MAP ICP)/CVR
  
• Referenced to the Foramen of Monroi

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CPP and Cerebral Oxygenation
Valadka A, Acta Neurochir 2002 Menzel M, J
Neurosurg Anesthesiol 1999 Doppenberg E, Surg
Neurol 1998
Individual increasing of CPP guided by PtiO2 gt10
mmHg decreased significantly amount of hypoxic
episodes after TBI.
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• 1. Why?
• 2. Critical Border ?
• 3. Time Course ?
• 4. Individual
• optimized CPP ?
• 5. Causes
• 6. Therapy

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• The optimal CPP in patients suffering from TBI is
  unclear.
• Recommendations
• From CPPgt50, gt 60 mmHg to CPPgt90 mmHg

• Reduced as well as high CPP influenced Outcome in
  a negative manner.
• Robertson et al. Crit Care Med 1999, Contant et
  al. J Neurosurg 2001 (n189)
• Balestreri et al. Neurocrit Care 2006 (n429)

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Outcome - Function of ICP and CPP
Balestreri et al Neurocritical Care 2006 N 429
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Optimal CPP
Brain Trauma Foundation, J Neurotrauma
2003,2007 CPP lt 70 mmHg

• Robertson C, Crit Care Med 1999Robertson et al.,
• Contant et al. J Neurosurg 2001 (n189)
• Balestreri et al. Neurocrit Care 2006 (n429)

CPP gt 60 mmHg Avoid CPP lt 50 mmHg Intact
Autoregulation CPP gt 70 mmHg
EBIC, Acta Neurochir 1997 CPP 6070 mmHg
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Optimized CPP - Therapy

TBI N 30 Episode gt 10 min
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• 1. Why?
• 2. Critical Border ?
• 3. Time Course ?
• 4. Individual
• optimized CPP ?
• 5. Causes
• 6. Therapy

ptiO2 lt 10 mmHg
ptiO2 lt 10 mmHg
Day 1-2
Day 3-5
Day 6-8
F R E Q U E N C Y
CPP mmHg
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• 1. Why?
• 2. Critical Border ?
• 3. Time Course ?
• 4. Individual
• optimized CPP ?
• 5. Causes
• 6. Therapy

Effect of reduced CBF
ml/100g/min
Edema, Lactate
Ischemia
Loss of electric activity
Penumbra
Loss of Na/K Pump, ATP
Infarction
Cell death
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• Concept individual optimized CPP (CPPopt)
• Steiner et al. Crit Care Med 2002 (n114)

• Based on continous monitoring of cerebrovascular
  pressure reactivity index PRX

• PRx moving correlation coefficient MAP / ICP
• Czosnyka et al. Neurosurgery 1997

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Individual optimized CPP
Steiner et al. Crit Care Med 2002
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Individual optimized CPP
PtiO2
Steiner et al. Crit Care Med 2002
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• Data analysis
• CPP vs. PRx
• CPP vs. PtiO2
• CPP-class of 5 mmHg

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Results

• CPPopt n28/33 (85 )

• CPPopt n7 60-65 mmHg
• n1 65-70 mmHg
• n8 70-75 mmHg
• n1 75-80 mmHg
• n6 80-85 mmHg
• n3 85-90 mmHg
• n2 90-95 mmHg

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PRx
CPP
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PRx
PtiO2
CPPopt
CPP
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PRx
CPP
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PRx
PtiO2
CPPopt
CPP
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PRx
PtiO2
n28
CPP
Jaeger et al Crit Care Med 2010
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• Therapeutic Options CPP gt 60, lt 70 mmHg
• Induced hypervolemia with cristalloids
• Cave heart insufficience
• No body/head elevation 0
• Inotropica infusion
• Cave acute coronary syndrome, arrhythmia
• Diuretics Reduction of centralvenous pressure
• Ventilation - best PEEP - concept
• Option Prognostic value only given by case
  reports

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• Management of CPP after TBI
• Recommendations
• Avoid CPP lt 50 mmHg to minimize edema
• 
  formation
• CPP gt 70 80 mmHg can improve perfusion if
• 
  autoregulation is intact
• Class II evidence CPP of 60 mmHg sufficient CBF
  and cerebral perfusion in most cases
• Ancillary monitoring is helpful to target CPP

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CPP Management - Protocols
White H, Venkatesh B Neurosurg Anesth 2008
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• Management of CPP after TBI
• Recommendations
• Need for more data
• Individualized optimal CPP
• based on hemodynamic
  monitoring/
• pressure
  autoregulation indices
• Randomized outcome studies

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Thank You for Your Attention !