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Direct cerebral oxygenation monitoring—a systematic review of recent publications

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Abstract

This review has been compiled to assess publications related to the clinical application of direct cerebral tissue oxygenation (PtiO2) monitoring published in international, peer-reviewed scientific journals. Its goal was to extract relevant, i.e. positive and negative information on indications, clinical application, safety issues and impact on clinical situations as well as treatment strategies in neurosurgery, neurosurgical anaesthesiology, neurosurgical intensive care, neurology and related specialties. For completeness’ sake it also presents some related basic science research. PtiO2 monitoring technology is a safe and valuable cerebral monitoring device in neurocritical care. Although a randomized outcome study is not available its clinical utility has repeatedly been clearly confirmed because it adds a monitoring parameter, independent from established cerebral monitoring devices. It offers new insights into cerebral physiology and pathophysiology. Pathologic values have been established in peer-reviewed research, which are not only relevant to outcome but are treatable. The benefits clearly outweigh the risks, which remains unchallenged in all publications retrieved. It is particularly attractive because it offers continuous, real-time data and is available at the bedside.

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Authors and Affiliations

  1. Neurosurgical Associates, Red Cross Hospital, Bergmannstraße 32, 34121, Kassel, Germany

    Erhard W. Lang

  2. Department of Neurosurgery, University of Sydney, Westmead Hospital, Sydney, Australia

    Erhard W. Lang, Jamin M. Mulvey & Nicholas W. C. Dorsch

  3. Department of Intensive Care, University of Sydney, Westmead Hospital, Sydney, Australia

    Yugan Mudaliar

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Comments

Ignacio J. Previgliano, Buenos Aires, Argentina

Brain tissue oxygenation, as demonstrated in this complete systematic review by Lang et al., is a promising technology. I agree that it offers continuous, real-time data and is available at the bedside safely. The rapid correlation between the indicated treatment and the regional response allowed by the devices is stimulating.

Beyond the applications updated in the review there is a potential use in early brain death diagnosis that should be borne in mind as a matter of research. Estimation of the best cerebral perfusion pressure and hyperventilation therapy control are, in my opinion, among the most important applications.

Nevertheless, there are some important issues to highlight regarding this technology. The Neurotrend device has been dropped off the market by Codman, Johnson and Johnson, so Licox is the only device available. There are no papers assessing sensitivity, specificity, positive and negative value as well as positive or negative likelihood ratio and pre- or post-test odds for the method as a prognostic or diagnostic tool, according to the principles of evidence-based medicine. There are also controversies on which region should be monitored: non-injured tissue, penumbra area or injured tissue, as well as which are the normal values or the pathologic threshold. Another controversy is the one that confronts regional vs global monitoring systems.

Even though well conducted and serious, most of the research has been done in Germany where the Gesellschaft für Medizinische Sondentechnik (GMS) developed the polarographic cell device, as is noted in the review references.

In view of these critical considerations that should be taken into account, brain tissue oxygenation should be considered a new star in the neurocritical monitoring constellation in which none is more important than the other and all of them are still looking for their right place.

Comment

Alexander Brawanski, Regensburg, Germany

In their paper the authors review the development and clinical application of the registration of cerebral oxygenation (PtiO2). They reviewed the pertinent literature from 2004 to 2006 with the aim of collecting the relevant information on clinical applicability, safety issues and clinical usefulness. All in all 1,400 publications were scanned. Mostly PtiO2 monitoring was used in traumatic brain injury (TBI) followed by subarachnoid hemorrhage. Less commonly it was used intraoperatively during cerebrovascular surgery. Other rarer applications, like during cardiopulmonary resuscitation or cerebral angiography, are included in the review. The authors report that PtiO2 monitoring is mostly used clinically in conjunction with additional cerebral monitoring devices like intracranial pressure (ICP) monitoring, jugular venous saturation monitoring, cerebral microdialysis and near infrared spectroscopy, just to name a few. Two different devices are on the market based on different technology and giving slightly different data. The main results of this review are that this methodology is safe and has an impact on clinical treatment of the above-mentioned patient groups. A safety range of tissue oxygen levels could be established, below that the outcome of the studied patients was significantly worse. Thus PtiO2 monitoring has a prognostic value. Negative effects of hyperventilation were detected and it was applied more safely as hypoxic cerebral oxygen levels were avoided. The indication for decompressive craniectomy in severe brain swelling could be guided by cerebral oxygen monitoring more safely. PtiO2 has also been proven useful in monitoring the use of vasoactive drugs given in neurocritical care as well as in elucidating effects of nimodipine and mannitol. There were no severe side effects using PtiO2 in patients. Both available probes measure oxygen tension sufficiently. However, the Licox technology seems to be more accurate than the Neurotrend monitor. The often quoted disadvantage of the “locality” of the measuring devices—they measure an area of a few cubic millimeters—could be alleviated by several publications. These could show that there is a certain random positioning error. On the other hand these local measurements correlated well with more global methods like cerebral blood flow. The authors conclude that PtiO2 monitoring is safe, clinically useful, and it improves the treatment of ICU patients. They favor, however, a multiparameter approach, meaning that other “brain” parameters should be monitored in addition. All in all this is a very informative study giving relevant and up-to-date information about this important monitoring technique.

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Lang, E.W., Mulvey, J.M., Mudaliar, Y. et al. Direct cerebral oxygenation monitoring—a systematic review of recent publications. Neurosurg Rev 30, 99–107 (2007). https://doi.org/10.1007/s10143-006-0062-4

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