Using microdialysis for clinical decisions in head injury
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Transcript of Using microdialysis for clinical decisions in head injury
CLINICAL DECISIONS BASED ON MICRODIALYSIS DATA IN SEVERE HEAD INJURY
P.G. Papanikolaou, E.Papadopoulos, A.Markellos, K.Barkas, S.Stamatiou, A.Venetikidis, N.Papageorgiou, M.Fratzoglou, E.Chatzidakis, T.Kyriakou, T.S. Paleologos, K.Kazdaglis
Neurosurgical Department,General Hospital of Nikea - Piraeus, Athens, Greece
NOTHING TO DISCLOSE
Οur experience
Multimodal neuromonitoring in TBI patients using intraparenchymal brain catheters
Twist hand drill burr hole Single same burr hole 5.3 mm 3 – lumen cranial bolt (LICOX) ICP, PtiO2, microdialysis
Treatment strategies
CPP targeted therapy
- CPP > 60 mm Hg - ICP < 20 mm Hg - PtiO2 > 20 mm Hg
- L / P ≤ 25
Catheter’s tip
What about microdialysis?
Microdialysis only for research
•Not officially recommended as a clinical tool in TBI
Some centers favour it
and not only in
Hillered L, Vespa PM, Hovda DA. Translational neurochemical research in acute human brain injury: the current status and potential future for cerebral microdialysis. J Neurotrauma. 2005 Jan;22(1):3-41.
Our center’s opinion
Clinical decisions based on microdialysis data -Lactate to Pyruvate concetrations’ ratio (L/P) - in severe head injury: Treatment protocol of patients with peaks of
intracranial hypertension up to 30 mmHg (“group A”)
Evaluation of success and duration of thiopenthal administration (“group B”)
Decision for evacuation or not of “border-line” sized hematomas (“group C”)
GROUP A max ICP mean L/P age sex GOS
Pt 1 33 32,7 59 f 5
Pt 2 35 31 43 m 5
Pt 3 35 24 22 f 4
Pt 4 28 20 27 m 5
Pt 5 31 31 29 m 5
Pt 6 29 23,1 41 m 4
GROUP B
Pt 1 40 32 28 m 5
Pt 2 117 28,4 17 m 1
Pt 3 122 42,7 41 m 1
Pt 4 37 31,1 35 m 5
Pt 5 121 46,7 28 m 1
Pt 6 98 41,2 39 m 5
GROUP C
Pt 1 27 30,7 32 m 1
Pt 2 34 24,6 21 m 4
Pt 3 14 23,8 23 m 5
Pt 4 27 28,7 22 m 5
Pt 5 40 32 28 m 5
Pt 6 33 32,7 59 f 5
Group A
6 patients episodes of intracranial hypertension
up to 30mmHg without significant change of the L/P
ratio Decision to treat with mannitol only
or to proceed to second tier therapy with barbiturates
Group A : Sporadic ICP elevations up to 30mmHg – just sedation and mannitol or something more aggressive ?
Group B
6 patients refractory intracranial hypertension treated by barbiturates L/P ratio was the main criteria for
evaluation and duration of the treatment
Group B : Conservative treatment. Barbiturate therapy for refractory intracranial hypertension. Evaluation of continuation of barbiturate induced coma
Normalization of L/P before ICP
Discharge CT scan
GOS 5 at 6 months
Group C
6 patients intracranial hematoma initially
treated conservatively L/P ratio in association with ICP
determined the decision for a surgical evacuation
Group C : 59 yrs, female Evacuation or not?
Based on values of L/P<25 : conservative treatment
CT scan at two months (discharge)
GOS 4 at 6 months
GOS
Good
Moderate
Bad
Group AGroup BGroup C
Handicaps
Difficulty of insertion of the catheter via the 3/lumen bolt
Measurement frequency ICU personnel deficiency done by N/S residents
Lack of automatic data registration National health system structure :
patients → ICU somewhere else Hospital and social insurance managers
not so helpful
Conclusions
Multimodal neuromonitoring using brain catheters seems to be safe, reliable and useful tool
Data provided by microdialysis seems to be helpful taking appropriate clinical decisions
Especially useful in barbiturate therapy
References1.Poca MA et al. Percutaneous implantation of cerebral microdialysis catheters by twist-drill
craniostomy in neurocritical patients: description of the technique and results of a feasibility study in 97 patients. J Neurotrauma. 2006 Oct;23(10):1510-7.
2. Tisdall MM et al Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006 Jul;97(1):18-25. Epub 2006 May 12
3. Hutchinson PJ. Microdialysis in traumatic brain injury--methodology and pathophysiology. Acta Neurochir Suppl. 2005;95:441-5
4. Martins RS et al. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. 2003 Aug;60(2):98-104
5. Sarrafzadeh AS et al. Detection of secondary insults by brain tissue pO2 and bedside microdialysis in severe head injury. Acta Neurochir Suppl. 2002;81:319-21.
6. Stahl N et al. Intracerebral microdialysis and bedside biochemical analysis in patients with fatal traumatic brain lesions. Acta Anaesthesiol Scand. 2001 Sep;45(8):977-85.
7. Hecimovic I et al. Intracranial infection after missile brain wound: 15 war cases. Zentralbl Neurochir. 2000;61(2):95-102.
8. Goodman JC et al. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients. J Neurotrauma. 1996 Oct;13(10):549-56.
9. Brain Trauma Foundation Guidelines 2007. J Neurotrauma 2007;24 Suppl 1:S91-5
10. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flow Monitoring. Intensive Care Med (2007) 33:1263–1271
11. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. II. Cerebral oxygenation monitoring and microdialysis. Intensive Care Med (2007) 33:1322–1328