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ICP Threshold Debate

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Mark Wilson and John Myburgh discuss intracranial pressure. Some fundamentals, some history to put it all in perspective and all the issues with focusing on just one number. Fascinating insights from two true experts.

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Publicada em: Saúde e medicina
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ICP Threshold Debate

  1. 1. ICP @JAMyburgh @MarkHWilson
  2. 2. ICP Variable to be targeted? Or Marker of Severity of Disease?
  3. 3. 1783 1824 18421828 1846 1926 “for, as the substance of the brain, like that of the other solids of our body, is nearly incompressible the quantity of blood within the head must be the same, or very nearly the same, at all times, whether in health or disease, in life or after death, those cases only excepted, in which water or other matter is effused or secreted from the blood-vessels; for in these, a quantity of blood, equal in bulk to the effused matter, will be pressed out of the cranium. ”
  4. 4. What Makes Intracranial Pressure
  5. 5. Idiopathic Intracranial Hypertension
  6. 6. W H E N I T C O M E S T O I C P T H I N K I N A N D O U T S I D E O F T H E B O X
  7. 7. Inputs: RCT - 15 centres, Aus, NZ + Saudi Arabia n = 155 ICP of > 20mmHg for > 15 minutes DC = 75 vs no DC in 82 Extended GOS at 6 months, favourable outcome Outputs: At 6 months: GOS-E worse in DC (Odds Ratio 1.8) Mortality DC = 19%, `standard care = 18% Post hoc adjustments for pupils —> no difference Mean ICP DC = 14.4 vs 19.1 and fewer ICU days. More fixed pupils in DC group (27% vs 12%)- removed statistically significant benefits when analysed. Conclusion: Crainectomy associated with more unfavrouable outcomes DECRA - 2002 -2010
  8. 8. Inputs: 52 centres in 12 countries n = 408 patients ICP >25mmHg for > 12 hours 201 surgery vs 188 medical Extended GOS at 6 months, favourable outcome Outputs at 6 months: Death: 26.9% in surgery vs 48.9% medical Veg State: 8.5% in surgery vs 2.1% medical Lower sever disability: 21.9% vs 14.9% Upper severe disability: 15.4 vs 8% Moderate severe disability: 23.4 vs 19.7% Good recovery 4.0 vs 6.9% Outputs at 12 months: Death: 30.4% in surgery vs 52% medical Veg State: 6.2% in surgery vs 1.7% medical Lower sever disability: 18% vs 14% Upper severe disability: 13.4% vs 3.9% Moderate severe disability: 22.2 vs 20.1% Good recovery 9.8 vs 8.4% RESCUE ICP - 2004 TO 2014
  9. 9. 100 patients treated with decompressive craniectomy rather than medical intent, there were 22 more survivors; of these 22 patients, 6 were in a vegetative state (27%), 8 were categorised as having lower severe disability (36%), and 8 were categorized as having upper severe disability  or better (36%)
  10. 10. WHEN?
  11. 11. HOW?
  12. 12. Robba: Int Care Med 2017
  13. 13. ΔP(mmHg) ΔV (ml) 1783, 1824 Alexander Monro 1733-1817 George Kellie 1720-1779
  14. 14. Rat / human model 20th century Take a young male rat. Infuse alcohol or ice until intoxicated. Throw rat at high speed into brick wall Break its femur and pelvis. Leave it lying in the corner for 1 hour. Get resident to resuscitate it using albumin and ketamine Include an oesophageal intubation and hypoxia for 20m. Get orthopod to fix femur and lose 20% blood volume. Do a CT head, but don’t tell the researcher the results. Get a resident to put in ICP monitor 6-36 hours after injury. Do the intervention. Random use of mannitol, hyperventilation, hypothermia, barbs Count how many rats are dead after 1 week.
  15. 15. www.braintrauma.org
  16. 16. Rat / human model 21th century Take a rat of any age. If young, infuse alcohol or speed until intoxicated. If old, give warfarin and aspirin Early intubation and resuscitation Pan-scan and damage control surgery Standardise ICP monitoring Do the intervention. Flog CPP with noradrenaline Use hypothermia, barbiturates to keep ICP<20 Decompressive craniectomy if these don’t work Keep going until the rat’s family tells you when to stop Count how many rats are dead after 6 months.
  17. 17. Noradre But you said…… “Keep the CPP above 70!??”
  18. 18. Cooper: New Eng J Med 2011 Unfavourable Favourable 70% 51% OR: 2.21 95%CI 1.14 to 4.26; P=0.0219 vs 18% mortality
  19. 19. Chesnut: NEJM 2012 ICP monitoring group Imaging/exam group P=0.60
  20. 20. Outcome from ABI is primarily determined by geography… … and genetics ICP is primarily an indicator of severity of injury Treating ICP comes at a cost … … saving the head, but killing the body… … and those who care for the patient
  21. 21. Beware the relentless therapeutic imperative to do what we can… … and not what we should
  22. 22. ICP Treat the cause not the number
  23. 23. ICP GAME OVER ?