Abstract
Based on continuous monitoring of the pressure reactivity index (PRx), we defined individualized intracranial pressure (ICP) thresholds by graphing the relationship between ICP and PRx. We hypothesized that an “ICP dose” based on individually assessed ICP thresholds might correlate more closely with 6-month outcome compared with ICP doses derived from the recommended universal thresholds of 20 and 25 mmHg. Data from 327 patients with severe traumatic brain injury (TBI) were analyzed. ICP doses were computed as the cumulative area under the curve above the defined thresholds in graphing ICP versus time. The term Dose 20 (D20) was used to refer to an ICP threshold of 20 mm Hg. The markers D25 and DPRx were calculated similarly. The discriminative ability of each dose with regard to mortality was assessed by receiver operating characteristics analysis using fivefold cross-validation (CV). DPRx was found to be the best discriminator of mortality, despite the fact that D20 was twice as large as DPRx. Individualized doses of intracranial hypertension were stronger predictors of mortality than doses derived from the universal thresholds of 20 and 25 mm Hg. The PRx could offer a method of individualizing the ICP threshold.
This work was performed in the Academic Neurosurgical Unit and the Neurosciences Critical Care Unit of Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Acknowledgments
The authors acknowledge great support from Addenbrooke’s Hospital Neurocritical Care Unit staff and Academic Neurosurgical Unit registrars, without whose help the collection of computerized data would never have succeeded. We also acknowledge Ming Yang MS for statistical assistance.
Conflicts of Interest and Source of Funding
The software for brain monitoring ICM+ (http://www.neurosurg.cam.ac.uk/icmplus) is licensed by the University of Cambridge (Cambridge Enterprise). Mr Czosnyka and Mr Smielewski have a financial interest in part of the licensing fee. Mr Hutchinson is supported by an Academy of Medical Sciences/Health Foundation Senior Scientist Fellowship and grants from the Medical Research Council/NIHR. Mr Menon is supported by funding from the Medical Research Council, the NIHR Cambridge Biomedical Centre, and an NIHR Senior Investigator award. Mr Pickard is a NIHR senior investigator awardee and a principal investigator within the NIHR Biomedical Research Centre (Cambridge University Hospital Foundation Trust) and lead principal investigator for the Medical Research Council “Acute Brain Injury Programme” grant. The remaining authors have not disclosed any potential conflict of interest.
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Lazaridis, C., Smielewski, P., Menon, D.K., Hutchinson, P., Pickard, J.D., Czosnyka, M. (2016). Patient-Specific Thresholds and Doses of Intracranial Hypertension in Severe Traumatic Brain Injury. In: Ang, BT. (eds) Intracranial Pressure and Brain Monitoring XV. Acta Neurochirurgica Supplement, vol 122. Springer, Cham. https://doi.org/10.1007/978-3-319-22533-3_23
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