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Correlation of brain flow variables and metabolic crisis: a prospective study in patients with severe traumatic brain injury

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European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Introduction

Current treatment guidelines for patients with severe TBI (sTBI) are aimed at preventing secondary brain injury targeting specific endpoints of intracranial physiology to avoid the development of metabolic crisis. We sought to identify factors contributing to development of metabolic crisis in the setting of a Multi-modality Monitoring and Goal-Directed Therapy (MM&GDTP) approach to patients with severe TBI.

Methods

Prospective monitoring of sTBI patients was performed, with retrospective data analysis. MM&GDTP was targeted to intracranial pressure (ICP) ≤ 20 mmHg, cerebral perfusion pressure (CPP) ≥ 60 mmHg, brain tissue oxygen pressure (PbtO2) ≥ 20 mmHg, and cerebral oxygen extraction measured by bi-frontal Near infrared Spectroscopy (NIRS) > 55%. Brain flow abnormality was defined by one of the following combinations: CPP < 60 mmHg with NIRS < 55% (Type 1), CPP < 60 mmHg with PbtO2 < 20 mmHg (Type 2), or PbtO2 < 20 mmHg with NIRS < 55% (Type 3). Cerebral micro-dialysate was analyzed hourly for glucose, lactate, pyruvate, glutamate, glycerol, and lactate/pyruvate ratio (LPR). Statistical analysis was performed with student t-test, chi-square and Pearson’s tests as applicable.

Results

A total of 109,474 consecutive minutes of recorded multimodality monitoring was available for analysis. There was a significant difference in the number of minutes of brain flow abnormalities between survivors and non-survivors: 0.8% (875) versus 7.49% (8,199), respectively (p < 0.05). The duration of Type 1–3 flow abnormality per patient was higher in non-survivors (5.7 ± 2.5 h) compared to survivors (0.7 ± 0.6 h) as well as the duration of metabolic crisis, namely, 5.2 ± 2.2 versus 0.6 ± 1.0 h per patient. The occurrence of severe metabolic crisis was associated with a Type 2 flow abnormality (CPP < 60 mmHg and PbtO2 < 20 mmHg), r = 0.97, p < 0.001, but not with Type 1 and 3.

Conclusions

Metabolic crisis can occur despite a MM&GDTP approach aimed at optimizing cerebral blood flow. Severe metabolic crisis is associated to failure to maintain CPP and PbtO2 above 60 and 20 mmHg, respectively. The occurrence of severe metabolic crisis portends a poor prognosis in patients with sTBI.

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Authors and Affiliations

  1. Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

    Corrado P. Marini & John McNelis

  2. Department of Surgery, New York Medical College, Valhalla, NY, USA

    Corrado P. Marini, Christy Stoller & Kartik Prabhakaran

  3. Integrated Service Maxillofacial Surgery, San Michele Hospital, Maddaloni, Caserta, Italy

    Vito Del Deo

  4. Department of Surgery, NYU Langone Health—NYU Winthrop Hospital, NYU Long Island School of Medicine, 222 Station Plaza North, Suite 300, Mineola, NY, 11501, USA

    Patrizio Petrone

Authors
  1. Corrado P. Marini
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  2. Christy Stoller
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  3. John McNelis
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  4. Vito Del Deo
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  5. Kartik Prabhakaran
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Contributions

Design: CPM. Data acquisition: CS. Analysis: CPM. Interpretation of data: CPM. Drafting of the manuscript: CPM, KP, PP. Critical revision: CPM, PP, JM, VDD.

Corresponding author

Correspondence to Patrizio Petrone.

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Conflict of interest

Corrado P. Marini, Christy Stoller, John McNelis, Vito Del Deo, Kartik Prabhakaran, and Patrizio Petrone declare that they have not conflict of interest.

Informed consent

This study is a retrospective chart review, and as such, there is no need for an informed consent. The New York Medical College Institutional Review Board approved the study design and methodology.

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Marini, C.P., Stoller, C., McNelis, J. et al. Correlation of brain flow variables and metabolic crisis: a prospective study in patients with severe traumatic brain injury. Eur J Trauma Emerg Surg 48, 537–544 (2022). https://doi.org/10.1007/s00068-020-01447-5

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  • DOI: https://doi.org/10.1007/s00068-020-01447-5

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