Neuromonitoreo Multimodal
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NEUROMONITOREO MULTIMODAL
Dra.Nilia Abad, [email protected], @abadnilia
HOSPITAL REBAGLIATI – LIMA 2013
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MONITOREO MULTIMODAL
“ Procesamiento de datos de diferentes técnicas de monitoreo en tiempo real, mediante sistemas computarizados integrados”
Journal of the Neurological Sciences 261 (2007) 10–15
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OBJETIVOS
Detectar eventos injuriantes “secundarios” para el cerebro o condiciones que amenacen la vida.
Evaluar la eficacia de la terapia Ayuda diagnóstica Formular pronóstico
Journal of the Neurological Sciences 261 (2007) 10–15
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MONITOREO CLINICO
Examinar al paciente
Evaluación neurológica y de todos los sistemas.
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¿MONITORIZAR LA PIC?
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¿MONITORIZAR LA PIC?
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PIC Y PRONÓSTICO
Neurotrauma p 425, 1995
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MONITOREO DE LA PIC
TEC : Nivel II ECG (3 a 8)
Hemorragia intracerebral espontánea: EG<8 , sospecha de herniación , HIV, hidrocefalia: Clase IIb, nivel de evidencia C
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MONITORES DE PIC Monitor Camino
(Integra Neurosciences)
Fibra óptica Transductor
integrado de presión y T
Zerado antes de la inserción
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MONITORES DE PIC
Codman ICP express
Microsensor Codman (tip)
Zero: usa líquido estéril
Zero offset number
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COMPARACION DE LOS DISPOSITIVOS DE PIC
Anesthesioly Clinics 25 (2007) 557 - 577
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MONITOREO DE LA PIC
Los drenajes intraventriculares conectados a transductores externos de presión son aun el Gold Estándar para el monitoreo de la PIC
Tasa de infección 10% Objetivo : PIC < 20mmHg
Intensive care Medicine (2008) 34: 1362 - 1370
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MONITOREO DE LA PIC
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MONITOREO DE LA PIC
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PRESIÓN DE PERFUSIÓN CEREBRAL
PPC 50 – 70 mmHg
PPC = PAM - PIC
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AUTOREGULACION
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AUTOREGULACION
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AUTOREGULACION
INTACTA: Guiar terapia por
PPC
No intacta: Guiar terapia por PIC
Pressure Reactivity Index: (PRx) PIC y PAM
Mx: Velocidades de flujo de ACM y MAP
Intensive care Medicine (2008) 34: 1362 - 1370
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REACTIVIDAD CEREBROVASCULAR
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OXIGENACIÓN TISULAR CEREBRAL GLOBAL
Saturación venosa del bulbo de la yugular
Umbrales no confiables
Usar tendencias
Journal of the Neurological Sciences 261 (2007) 10–15
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SJVO2
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OXIGENACIÓN TISULAR CEREBRAL
REGIONAL
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NIRS (Near Infrared Spectroscopy)
Transmisión y absorción de la luz cercana al infrarojo (700 -1000nm)
Ignora el componente pulsátil
rSO2
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NIRS
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LICOX
Sistema Licox Mide PbtO2 , temperatura y PIC Técnica polarográfica: Electrodo de Clark Indica eventos hipóxicos o isquémicos
antes que la PIC y PPC PtiO2 < 15 mmhg varias ocasiones o PtiO2
< 5 mmHg una vez: Pobre pronóstico en TEC
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LICOX
Principales indicaciones: TEC y HSA.
TEC:Disminución de
mortalidad ( estudios pequeños)
Colocación en tejido normal y/o pericontusional
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LICOX HSA:
SOP: oclusión vascular
Monitoreo del tejido perihematoma
Vasoespasmo – DCI : monitoreo de la terapia
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LICOX
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LICOX
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NEUROTREND
Mide Ph, PBCO2, PBO2 Luminiscencia óptica
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POST HEMICRANIECTOMIA
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MICRODIALISIS CEREBRAL
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MICRODIALISIS CEREBRAL
Injurias difusas: región frontal derecha
Injurias focales: 2 catéteres
TEC (principal indicación)
HSA
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MICRODIALISIS CEREBRAL
FUNDAMENTOS
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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MICRODIALISIS CEREBRAL
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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INCREMENTO DE GLICEROL
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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MICRODIALISIS CEREBRAL
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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MICRODIALISIS CEREBRAL
Glucosa Lactato Piruvato Glicerol Glutamato
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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MICRODIALISIS CEREBRAL
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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MICRODIALISIS CEREBRAL
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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MICRODIALISIS CEREBRAL
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BOMBA PERFUSORA
CMA 106 LCR artificial (0.3
ml/min)
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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ANALIZADORES CMA 600 (FDA 2005) ISCUSflex (FDA 2009) Calibración automática cada 6 horas
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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VALORES NORMALES
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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ALGORITMO PROPUESTO
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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PUPILOMETRÍA Pupilómetro :
Neuroptics Foresite (Medtronics)
Velocidad de constricción: < 0.8 mm/s< 0.6 mm/s : PIC
Traumatic Brain Injury: Advanced Multimodal Neuromonitoring. Crit Care N 2010. In Press
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FLUJO SANGUINEO CEREBRAL
Flujometría Laser Doppler
Detecta cambios cualitativos en el FSC
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FLUJO SANGUINEO CEREBRAL
Sistema HEMEDEX (Codman ]Shurtleff, Inc)
Perfusión tisular en tiempo real a nivel capilar (N: 18 – 35 ml/100gr/min)
Catéter con termistor proximal y distal
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FLUJO SANGUINEO CEREBRAL
HEMEDEX Medición por
difusión térmica
1.- Hemedex
2.- DVE
3.- Catéter Licox
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MONITOREO MULTIMODAL
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Sonografía Doppler Transcraneal
Vasoespasmo y HSA
Evaluación de la autoregulación
Evaluación de la vasoreactivad (CO2)
Muerte cerebral
Anesthesioly Clinics 25 (2007) 557 - 577
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Sonografía Doppler Transcraneal
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ELECTROENCEFALOGRAMA CONTINUO
(cEEG)
¿A quienes?Pacientes que no despiertan luego de
suspender sedación , no razones metabólicas o estructurales que lo expliquen
Monitorizar burst suppresion (coma barbitúrico)Movimientos dudosos
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ELECTROENCEFALOGRAMA CONTINUO (cEEG)
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APLICACIONES CLÍNICAS
HSA Fisher IV, Monitoreo MM
muestra: elevación del ratio Lactato/ Piruvato además de disminución de la PtiO2
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APLICACIONES CLÍNICAS
Varón 57 años HTA HSA: ruptura de
aneurisma de ACI derecha
Embolizado con éxito
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APLICACIONES CLÍNICAS
Arteriografía en el quito día post hemorragia.
Vasoespasmo de la ACM y la ACA derecha.
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MONITOREO MULTIMODAL
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MONITOREO MULTIMODAL
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APLICACIONES CLÍNICAS
Mujer 34 años Tabaquismo HSA Fisher IV Aneurisma de
la comunicante anterior
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APLICACIONES CLÍNICAS
Embolizada con éxito
Se demuestra severo vasoespasmo de las ACAs
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PtiO2 y CO2
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OSMOTERAPIA
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PtiO2 y Osmóticos
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GC y PtiO2
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AUTOREGULACIÓN: PRX
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AUTOREGULACIÓN: ORX
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AUTOREGULACIÓN: ORX
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EQUIPOS PARA MONITOREO MULTIMODAL
A: Visualizador de datos de microdiálisis
Monitor Licox Analizador de
Microdiálisis Monitor Sjvo2 (Abott
Oximetrix)
Anesthesioly Clinics 25 (2007) 557 - 577
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MENSAJES CLAVE El MMM, ayuda a evaluar la respuesta individual y
guiar la intervención terapéutica : comatosos.
El MMM más protocolos estandarizados conllevan a mejorar el pronóstico. Valorar las tendencias.
Mejorar las interfaces y las bases de datos para incrementar la disponibilidad del MMM en el mundo.
Se necesitan aun más estudios para validar el papel del MMM.
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Próximamente….