頭部外傷とICP - JSEPTIC

1 ICP ICU Introduction (ICP) , J Trauma. 2008;64:854 862, Can. J. Neurol. Sci. 2000; 27: 143-147, Intensive Care ;27:400-406 JOURNAL OF NEUROTRAUMA 29:2022 2029 ( July 20, 2012), JOURNAL OF NEUROTRAUMA;24, Supplement 1, 2007 Guidelines for the Management of Severe Traumatic Brain Injury 3rd Edition GCS 3-8 CT ICP CT 2 ICP > 40 sBP<90mmHg ICP Guidelines for the Management of Severe Traumatic Brain Injury 3rd Edition Medline search ~ April 2006 ICP >20mmHg ICP CT ICP In a randomized controlled trial in 3 trauma centers in Bolivia, test the effect on outcomes of management of severe TBI guided by information from ICP monitors vs.

2 A standard empiric protocol. ICP N Engl J Med 2012;367:2471-81. Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST:TRIP) trial Introduction ICP ICP 6 Methods Study Design multicenter RCT 4 2 24 ICP (ICE) Eligibility 13 48 8 1 5 Inclusion and exclusion criteria GCS3 Methods Group Assignments and Interventions: GCS:3-5 or M:1-2 vs. GCS:6-8 or M:3-5 40 vs. 40 CT 48 5 7 (ICP) ICP20mmHg (ICE) PCO2 30 35mm Hg Treatment Protocols - General Guidelines for the Management of Severe Traumatic Brain Injury Patients:ICP Monitor Group Treatment Goals: a.

3 ICP 20 mmHg b. Cerebral Perfusion Pressure (CPP) 50-70 mmHg c. Arterial blood oxygen saturation (SaO2) > 90% or PaO2 > 60 mm Hg Initial Therapeutic Interventions: a. NaCl to obtain a CVP of 10-12 cmH2O b. MAP > 70 mmHg c. Maintain PaCO2 35-40 mmHg if CT is normal Guidelines for the Management of Severe Traumatic Brain Injury Patients:ICP Monitor Group ICP Monitor with Elevated ICP Treatment algorithm: 5 ICP Basic treatment 20 Second tier therapy Basic treatment Mild hyperventilation (PaCO2 30-35 mmHg) Hypotension, Hypovolemia, Hyponatremia gm/kg 20%Mannitol bolus(plasma osmolarity < 320 ) plasma osmolarity > 360,tonicity > 380,serum sodium > 160 5%NaCl solution 100ml volus(plasma osmolarity < 360 and serum sodium < 160 ) Guidelines for the Management of Severe Traumatic Brain Injury Patients.

4 ICP Monitor Group Decrease in the motor GCS > 2,New loss of pupil reactivity, Interval development of pupil asymmetry of > 2mm,New focal motor deficit,Herniation syndrome 20%Mannitol bolus Maintain PaCO2 of 25-30 mmHg High dose IV barbiturates Thiopental mg/kg/hr IV continuous infusion for 3days Second tier therapy High dose IV barbiturates Thiopental mg/kg/hr IV) Hyperventilation(PaCO2 25-30 mmHg) Guidelines for the Management of Severe Traumatic Brain Injury Patients:Imaging and Clinical Exam (ICE) Group Methods primary outcome 21 Galveston Orientation and Amnesia Test [GOAT] 3 6 [GOAT]Extended Glasgow Outcome Scale [GOS-E] Disability Rating Scale[DRS] 6 MMSE 15 21 0 100 Methods secondary outcomes 1 Methods Methods Statistical Analysis.

5 N=324 GOS-E 10 80 6 Primary outcome the blocked Wilcoxon test Cox 1 Result 2008 9 2011 10 528 204 39% 92% 6 Study Participants Result 2 45% Result Clinical Outcomes primary outcome 2 Result 2 14 21% 30% (hazard ratio, ; 95% confidence interval [CI], to ; P = ) 6 39% 41% (hazard ratio, ; 95% CI, to ; P = ) CT Result Processes of Care ICU 2 (P= ) 12% vs 5%; P = ICP ICP>20mm Hg 7 (20% ) 5 (13%) ICP>20mm Hg 37% 29% 79% 76% ICP>20mm Hg vs P= Result (P ) 72% vs 58%,P= 73% vs 60%,P= (21 hours vs.)

6 13 hours for mannitol, 21 hours vs. 10 hours for hypertonic saline) 24% vs. 13%,P= (P= ) Result Adverse Events Discussion CT ICP ICP 20mm Hg non randomized controlled trials 20mmHg Guidelines for the management of severe head injury - Neurotrauma 2000;17:457-62., Crit Care Med 2005;33:2207-13., J Trauma 2008;64:335-40., J Neurosurg 1986;65:820-4. Discussion CSF Neurosurg Focus 2001;11(4):E1., Brain Inj 2010;24:706-21. ICP CT ICP ICP Discussion Limitation: 6 14 35% Discussion Limitation: J Neurosurg 1986;65:820-4.

7 ICP ICP ICP Editorial ICP ICU ICP CSF ICP ICP 20mmHg ICP Editorial ICP ICU ICP ICP ICP