Timmons, Shelly

Neuromonitoring Techniques in the Neuro ICU: Brain Tissue Oxygenation Shelly D. Timmons, MD, PhD, FACS, FAANS Director of Neurotrauma Geisinger Health System July 17, 2011

Learning Objectives ,[object Object],[object Object],[object Object],[object Object]

Balanced Approach ,[object Object],[object Object]

TBI Treatment Goals ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

ICP MAP CBF P bt O 2 Brain Temp Na Osm Plt PT PTT Hgb Hct ABG Gluc Microdialysis CPP SjvO 2 EEG ECOG Neurological Exam Imaging Operative Findings

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Jugular Venous O 2 Saturation

Jugular Venous O 2 Saturation ,[object Object],[object Object],[object Object],[object Object],From: Anesth Analg. 2000 Mar;90(3):559-66 Schell RM, Cole DJ. Techniques may be complimentary

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cerebral Blood Flow

Cerebral Blood Flow Monitor ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],Brain Tissue Oxygenation (pB t O 2 )

Brain Tissue Oxygenation P bt O 2 ,[object Object],[object Object],[object Object]

A closed polarographic probe with reversible electrochemical reactions Brain Tissue Oxygenation P bt O 2

[object Object],[object Object],[object Object],[object Object],[object Object],Brain Tissue Oxygenation P bt O 2

Insertion Technique ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Techniques ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Brain Oxygen Monitoring Guidelines 2008 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Indications ,[object Object],[object Object]

P bt O 2 ,[object Object],[object Object],Bardt TF, Unterberg AW, Hartl R, et al. Acta Neurochir 1998; 71:153–156 Dings J, Ja¨ger A, Meixensberger J, et al. Neurol Res 1998; 20(Suppl 1):S71–S75

[object Object],Timmons, SD Crit Care Med . 2010 Sep;38(9 Suppl):S431-44. These effects may be independent of effects on ICP or CPP

P bt O 2 and Mortality ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Bardt TF, Unterberg AW, Hartl R, et al. Acta Neurochir 1998; 71:153–156 N.B. Good outcomes are possible even with hypoxic episodes

P bt O 2 and Mortality ,[object Object],[object Object],[object Object],[object Object],[object Object],Bardt et al. 1998 6-Month GOS 35 Severe TBI Pts.

Low P bt O 2 and Mortality ,[object Object],[object Object],[object Object],Valadka AB, Gopinath SP, Contant CF, et al. Crit Care Med 1998; 26:1576–1581 Dings J, Ja¨ger A, Meixensberger J, et al. Neurol Res 1998; 20 (Suppl 1):S71–S75

Low P bt O 2 and Mortality ,[object Object],[object Object],[object Object],[object Object],[object Object],6-Month GOS 101 Severe TBI Patients Van den Brink et al. 2000 Effects of obliterated cisterns

Low P bt O 2 and Mortality ,[object Object],[object Object],[object Object],[object Object],Stiefel MF, Spiotta A, Gracia VH, et al. J Neurosurg 2005; 103:805–811 Stiefel MF, Udoetuk JD, Spiotta AM, et al. J Neurosurg 2006; 105:568–575 Narotam PK, Morrison JF, Nathoo N J Neurosurg 2009; 111:672–682

Low P bt O 2 Causes ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Artru F, Jourdan C, Perret-Liaudet A, et al. Neurol Res 1998; 20:S48–S51

Techniques to Improve P bt O 2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Artru F, Jourdan C, Perret-Liaudet A, et al. Neurol Res 1998; 20:S48–S51 Cormio M, Gopinath SP, Valadka AB, et al. J Neurotrauma 1999; 16:927–936 Johnston AJ, Steiner LA, Coles JP, et al. Crit Care Med 2005; 33:189–195 Oddo M, Levine JM, Frangos S, et al. J Neurol Neurosurg Psych 2009; 80:916–920 Narotam PK, Morrison JF, Nathoo N J Neurosurg 2009; 111:672–682 Kiening KL, Ha¨rtl R, Unterberg AW, et al. Neurol Res 1997;19:233–240 Imberti R, Fuardo M, Bellinzona G, et al. J Neurosurg 2005; 102:455–459 Thorat JD, Wang EC, Lee KK, et al. J Clin Neurosci 2008;15: 143–148 Chen HI, Malhotra NR, Oddo M, et al. Neurosurgery 2008;63:880–997

Techniques to Improve P bt O 2 ,[object Object],[object Object],[object Object],[object Object],Smith MJ, Stiefel MF, Magge S, et al. Crit Care Med 2005; 33:1104–1108 Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A, et al. Intensive Care Med 2006; 32: 1733–1740 Zygun DA, Nortje J, Hutchinson PJ, et al. Crit Care Med 2009; 37:1074–1078

Techniques to Improve P bt O 2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Artru F, Jourdan C, Perret-Liaudet A, et al. Neurol Res 1998; 20:S48–S51 Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A, et al. Intensive Care Med 2006; 32: 1733–1740 Smith MJ, Stiefel MF, Magge S, et al. Crit Care Med 2005; 33:1104–1108

Techniques to Improve P bt O 2 ,[object Object],[object Object],Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A, et al. Intensive Care Med 2006; 32: 1733–1740 Zygun DA, Nortje J, Hutchinson PJ, et al. Crit Care Med 2009; 37:1074–1078 Weigh well-documented risks vs. the potential benefit of protection from secondary injury

Techniques to Improve P bt O 2 ,[object Object],[object Object],[object Object],Tolias CM, Reinert M, Seiler R, et al. J Neurosurg 2004; 101: 435–444 Nortje J, Coles JP, Timofeev I, et al. Crit Care Med 2008; 36:273–280 Diringer MN, Aiyagari V, Zazulia AR, et al. J Neurosurg 2007; 106: 526–529

Techniques to Improve P bt O 2 ,[object Object],[object Object],[object Object],[object Object],[object Object],Rockswold GL, Solid CA, Paredes-Andrade E, et al. Neurosurg 2009; 65:1035–1042 Rosenthal G, Hemphill JC, Sorani M, et al. Crit Care Med 2008 Jun; 36:1917–1924

Techniques to Improve P bt O 2 ,[object Object],Stiefel MF, Heuer GG, Smith MJ, et al. J Neurosurg 2004; 101:241–247 Ho CL, Wang CM, Lee KK, et al. J Neurosurg 2008; 108:943–949 Used w/ permission: William Coplin, M.D. Contralateral to Surgical Site

Relationship to CBF ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Oxygen Diffusion ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Low P bt O 2 may be more closely related to impaired oxygen diffusion rather than oxygen delivery or metabolism. Diringer MN, Aiyagari V, Zazulia AR, et al. J Neurosurg 2007; 106: 526–529 Menon D, Coles JP, Gupta AK, et al. Crit Care Med 2004 Jun; 32: 1384–1390 Rockswold SB, Rockswold GL, Zaun DA, et al. J Neurosurg 2010; 112:1080–1094 Mannitol

Potential Problems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Van Santbrink H, Maas AIR, Avezaat CJJ Neurosurgery 1996; 38: 21–31 Dings J, Meixensberger J, Roosen K J Neurological Res 1997; 19:1–5 Van den Brink WA, Van Santbrink H, Steyerberg EW, et al. Neurosurgery 2000; 46: 868–878 Anderson, RCE, Kan P, Klimo P, et al. J Neurosurg (Pediatrics 2) 101:53–58, 2004

Assessing Physiology of Secondary Injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Future of Neuromonitoring ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Not Just ICP Control But Also Metabolism-Driven Therapy

TBI Advisor Evidence-Based Treatments  Interventions

Timmons, Shelly

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