title: Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury.
abstract: OBJECTIVE
  We have sought to develop an automated methodology for the continuous updating of optimal cerebral perfusion pressure (CPPopt) for patients after severe traumatic head injury, using continuous monitoring of cerebrovascular pressure reactivity. We then validated the CPPopt algorithm by determining the association between outcome and the deviation of actual CPP from CPPopt.
  
  
  METHODS
  Retrospective analysis of prospectively collected data.
  
  
  METHODS
  Neurosciences critical care unit of a university hospital.
  
  
  METHODS
  A total of 327 traumatic head-injury patients admitted between 2003 and 2009 with continuous monitoring of arterial blood pressure and intracranial pressure.
  
  
  RESULTS
  Arterial blood pressure, intracranial pressure, and CPP were continuously recorded, and pressure reactivity index was calculated online. Outcome was assessed at 6 months. An automated curve fitting method was applied to determine CPP at the minimum value for pressure reactivity index (CPPopt). A time trend of CPPopt was created using a moving 4-hr window, updated every minute. Identification of CPPopt was, on average, feasible during 55% of the whole recording period. Patient outcome correlated with the continuously updated difference between median CPP and CPPopt (chi-square=45, p<.001; outcome dichotomized into fatal and nonfatal). Mortality was associated with relative "hypoperfusion" (CPP<CPPopt), severe disability with "hyperperfusion" (CPP>CPPopt), and favorable outcome was associated with smaller deviations of CPP from the individualized CPPopt. While deviations from global target CPP values of 60 mm Hg and 70 mm Hg were also related to outcome, these relationships were less robust.
  
  
  CONCLUSIONS
  Real-time CPPopt could be identified during the recording time of majority of the patients. Patients with a median CPP close to CPPopt were more likely to have a favorable outcome than those in whom median CPP was widely different from CPPopt. Deviations from individualized CPPopt were more predictive of outcome than deviations from a common target CPP. CPP management to optimize cerebrovascular pressure reactivity should be the subject of future clinical trial in severe traumatic head-injury patients.
authors.affiliation: Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, and Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, UK. m.j.h.aries@umcg.nl
authors.forename: Marcel J H
authors.initials: MJ
authors.lastname: Aries
authors.forename: Marek
authors.initials: M
authors.lastname: Czosnyka
authors.forename: Karol P
authors.initials: KP
authors.lastname: Budohoski
authors.forename: Luzius A
authors.initials: LA
authors.lastname: Steiner
authors.forename: Andrea
authors.initials: A
authors.lastname: Lavinio
authors.forename: Angelos G
authors.initials: AG
authors.lastname: Kolias
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Hutchinson
authors.forename: Ken M
authors.initials: KM
authors.lastname: Brady
authors.forename: David K
authors.initials: DK
authors.lastname: Menon
authors.forename: John D
authors.initials: JD
authors.lastname: Pickard
authors.forename: Peter
authors.initials: P
authors.lastname: Smielewski
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001794:Blood Pressure / Q000502:physiology; D001930:Brain Injuries / Q000503:physiopathology*; D002560:Cerebrovascular Circulation / Q000502:physiology*; D005260:Female; D006801:Humans; D007427:Intracranial Pressure / Q000502:physiology; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult