Valor pronóstico del monitoreo de la hemodinamia y el metabolismo cerebral del paciente neurocrítico

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Abstract

Se reporta que en la actualidad existe una serie de sistemas de monitoreo para el paciente neurocrítico, que son decisivos en su manejo. Se determinó el valor para predecir los resultados al alta de la Unidad de Cuidados Intensivos (UCI), de un grupo de variables del metabolismo y la hemodinamia cerebral. Se estudiaron los pacientes neurocríticos ingresados durante 1 año en la UCI del Centro de Investigaciones Médico-Quirúrgicas (CIMEQ); se recogieron los valores de presión intracraneal (PIC), tensión arterial media (TAM), presión de perfusión cerebral (PPC), presión yugular de oxígeno (PyO2), saturación yugular de oxígeno (SyO2), extracción yugular de oxígeno (ECO2), y diferencia arterio-yugular de oxígeno (DayO2), a las 24 horas del ataque inicial. Se dividieron los casos en grupo I (G-I), egreso de UCI por mejoría, y su grupo II (G-II), egreso fallecido. Los resultados se expresan en las medianas de las distintas variables que fueron PIC: G-I: 7 mmHg, G-II: 25 mmHg (p=0,0143), PPC: G-I: 79,1 mmHg, G-II: 71,6 mmHg; SyO2: G-I: 79,8 %, G-II: 63,3 %; ECO2: G-I: 18 %, G-II: 35 % y se concluye que la PIC elevada a las 24 horas del ataque cerebral inicial fue un predictor de mal resultado al alta en la UCI.

Translated abstract

At present, it is reported that there is a series of monitoring systems, which are decisive for the management of neurocritical patients. The value of a group of brain hemodynamics and metabolism variables for predicting outcome at discharge from ICU was determined. A study was conducted on neurocritical patients admitted to the ICU in the Medical & Surgical Research Center (CIMEQ) during a year. Twenty-four hours after the initial stroke, the values of intracranial pressure (ICP), mean blood pressure (MBP), cerebral perfusion pressure (BPP); jugular venous oxygen pressure (JOP); jugular venous oxygen saturation (JOS), jugular venous oxygen extraction (JOE) and arterio-jugular oxygen difference (AJOD) were taken. Cases were divided into group I (G-1) embracing discharges from ICU due to improvement of patient’s condition and group II (G-II) including discharges from ICU due to death of patients. The results are expressed as medians of the different variables such as iCP in g-I:7mmHg, G-II:25 mmHg (p=0,0143); BPP in g-I: 79,1 mmHg, G-II:71,6 mmHg; JOS in G-I: 79,8%, G-II: 63,3%; JOE in g-I: 18%, G-II:35%. It is concluded that high ICP 24 hours after the initial stroke was a predictor of bad outcome at discharge from ICU.

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Most cited references 21

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Further experience in the management of severe head injury.

J. Butterworth, Guy E J Faulkner, J. Harbison … (1981)

A prospective and consecutive series of 225 patients with severe head injuries who were managed in a uniform way was analyzed to relate outcome to several clinical variables. Good recovery or moderate disability were achieved by 56% of the patients, 10% remained severely disabled or vegetative, and 34% died. Factors important in predicting a poor outcome included the presence of intracranial hematoma, increasing age, abnormal motor responses, impaired or absent eye movements or pupil light reflexes, early hypotension, hypoxemia or hypercarbia, and elevation of intracranial pressure over 20 mm Hg despite artificial ventilation. Most of these predictive factors were assessed on admission, but a subset of 158 patients was identified in whom coma was present on admission and was known to have persisted at least until the following day. Although the mortality in this subset (40%) was higher than in the total series, it was lower than in several comparable reported series of patients with severe head injury. Predictive correlations were equally strong in the entire series and in the subset of 158 patients with coma. A plea is made for inclusion in the definition of "severe head injury" of all patients who do not obey commands or utter recognizable words on admission to the hospital after early resuscitation.

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Jugular venous desaturation and outcome after head injury.

Fiona Robertson, S. Gopinath, C. Hayes … (1994)

Early experience with continuous monitoring of jugular venous oxygen saturation (SjvO2) suggested that this technology might allow early identification of global cerebral ischaemia in patients with severe head injury. The purpose of the present study was to examine the relationship between episodes of jugular venous desaturation and neurological outcome. One hundred and sixteen severely head-injured patients had continuous monitoring of SjvO2 during days 1-5 after injury. Episodes of jugular venous desaturation (SjvO2 < 50% for more than 10 minutes) were prospectively identified, and the incidence of desaturation was correlated with neurological outcome: 77 episodes of desaturation occurred in 46 of the 116 patients; 27 had one episode and 19 had multiple episodes of desaturation. The causes of these episodes were systemic (n = 36), cerebral (n = 35), or both (n = 6). Most of the episodes were less than 1 hour in duration, and it is probable that many of them would not have been detected without continuous measurement of SjvO2. Episodes of desaturation were most common on day 1 after injury, and were twice as common in patients with a reduced cerebral blood flow as in patients with a normal or elevated cerebral blood flow. The occurrence of jugular venous desaturation was strongly associated with a poor neurological outcome. The percentage of patients with a poor neurological outcome was 90% with multiple episodes of desaturation and 74% in patients with one desaturation, compared to 55% in patients with no episodes of desaturation. When adjusted for all co-variates that were found to be significant, including age, Glasgow coma score, papillary reactivity, type of injury, lowest recorded cerebral perfusion pressure, and highest recorded temperature, the incidence of desaturation remained significantly associated with a poor outcome. Although a cause and effect relationship with outcome cannot be established in this study, the data suggest that monitoring SvO2 might allow early identification and therefore treatment of many types of secondary injury to the brain.

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Cerebral perfusion pressure management in head injury.

Bettina Rosner, S Daughton (1990)

A method of ICP management is presented based upon maintenance of cerebral perfusion pressure ( CPP = SABP - ICP) at 70-88 mm Hg or in some cases greater. To do this, we have employed volume expansion, nursed patients in the flat position, and actively used catecholamine infusions to maintain the SABP side of the CPP equation at levels necessary to obtain the target CPP. CSF drainage and mannitol have freely been used to maintain the ICP portion of the equation. Thirty-four consecutive patients with GCS less than or equal to 7 were admitted to the Neurosurgical Intensive Care Unit (GCS = 5.1 +/- 1.4) and managed with this protocol. CPP was maintained at 84 +/- 11 mm Hg, ICP was 23 +/- 9.8 mm Hg, and SABP averaged 106 +/- 11 mm Hg. CVP was 8.0 +/- 3.7 mm Hg and average fluid intake was approximately 5.4 +/- 3.9 liters/d. Output averaged 5.0 +/- 4.0 liters/d; additionally, albumin (25%) (33 +/- 44 gm/d) and PRBCs were used for vascular expansion and hemoglobin was maintained (11.5 +/- 1.4 gm/dl). Three patients died of uncontrolled ICP (all protocol errors). Four other patients succumbed, none secondary to ICP and all secondary to potentially avoidable complications. Morbidity (GOS = 4.2 +/- 0.87) appeared to be as good or superior to previous methods of therapy. Overall, mortality was 21% and that from uncontrollable ICP was 8%. This approach to the management of intracranial hypertension proved safe, rational, and greatly enhanced the therapeutic options available. It was also consistent with optimal care of other organ systems. The results bring into question many of the standard tenets of neurosurgical ICP management and suggest new avenues of investigation.

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Author and article information

Contributors

Anselmo Abdo Cuza: Role: ND

Javier Figueredo Méndez: Role: ND

Roberto Castellanos Gutiérrez: Role: ND

Francisco Gómez Peyre: Role: ND

Journal

Journal ID (publisher): mil

Title: Revista Cubana de Medicina Militar

Abbreviated Title: Rev Cub Med Mil

Publisher: ECIMED (Ciudad de la Habana )

ISSN: 1561-3046

Publication date (Print): December 2001

Volume: 30

Issue: suppl 5

Pages: 20-24

Affiliations

[1 ] Centro de Investigaciones Médico-Quirúrgicas Cuba

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Publisher ID: S0138-65572001000500004

SO-VID: 53e0e2e7-febd-44d9-a662-b2787e1684b2

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http://creativecommons.org/licenses/by/4.0/

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SciELO Cuba

Self URI (journal page): http://scielo.sld.cu/scielo.php?script=sci_serial&pid=0138-6557&lng=en

Valor pronóstico del monitoreo de la hemodinamia y el metabolismo cerebral del paciente neurocrítico Translated title: Predictive value of the monitoring of cerebral hemodynamics and metabolism in the neurocritical patients

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Most cited references 21

Further experience in the management of severe head injury.

Jugular venous desaturation and outcome after head injury.

Cerebral perfusion pressure management in head injury.

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