Baseline pressure errors (BPEs) extensively influence intracranial pressure scores: results of a prospective observational study

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Abstract

Background

Monitoring of intracranial pressure (ICP) is a cornerstone in the surveillance of neurosurgical patients. The ICP is measured against a baseline pressure (i.e. zero - or reference pressure). We have previously reported that baseline pressure errors (BPEs), manifested as spontaneous shift or drifts in baseline pressure, cause erroneous readings of mean ICP in individual patients. The objective of this study was to monitor the frequency and severity of BPEs. To this end, we performed a prospective, observational study monitoring the ICP from two separate ICP sensors (Sensors 1 and 2) placed in close proximity in the brain. We characterized BPEs as differences in mean ICP despite near to identical ICP waveform in Sensors 1 and 2.

Methods

The study enrolled patients with aneurysmal subarachnoid hemorrhage in need of continuous ICP monitoring as part of their intensive care management. The two sensors were placed close to each other in the brain parenchyma via the same burr hole. The monitoring was performed as long as needed from a clinical perspective and the ICP recordings were stored digitally for analysis. For every patient the mean ICP as well as the various ICP wave parameters of the two sensors were compared.

Results

Sixteen patients were monitored median 164 hours (ranges 70 – 364 hours). Major BPEs, as defined by marked differences in mean ICP despite similar ICP waveform, were seen in 9 of them (56%). The BPEs were of magnitudes that had the potential to alter patient management.

Conclusions

Baseline Pressure Errors (BPEs) occur in a significant number of patients undergoing continuous ICP monitoring and they may alter patient management. The current practice of measuring ICP against a baseline pressure does not comply with the concept of State of the Art. Monitoring of the ICP waves ought to become the new State of the Art as they are not influenced by BPEs.

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Most cited references 21

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A trial of intracranial-pressure monitoring in traumatic brain injury.

Randall Chesnut, Nancy Temkin, Nancy Carney … (2012)

Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).

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Monitoring and interpretation of intracranial pressure.

Derek J. Pickard, M Czosnyka (2004)

Intracranial pressure (ICP) is derived from cerebral blood and cerebrospinal fluid (CSF) circulatory dynamics and can be affected in the course of many diseases of the central nervous system. Monitoring of ICP requires an invasive transducer, although some attempts have been made to measure it non-invasively. Because of its dynamic nature, instant CSF pressure measurement using the height of a fluid column via lumbar puncture may be misleading. An averaging over 30 minutes should be the minimum, with a period of overnight monitoring in conscious patients providing the optimal standard. Computer-aided recording with online waveform analysis of ICP is very helpful. Although there is no "Class I" evidence, ICP monitoring is useful, if not essential, in head injury, poor grade subarachnoid haemorrhage, stroke, intracerebral haematoma, meningitis, acute liver failure, hydrocephalus, benign intracranial hypertension, craniosynostosis etc. Information which can be derived from ICP and its waveforms includes cerebral perfusion pressure (CPP), regulation of cerebral blood flow and volume, CSF absorption capacity, brain compensatory reserve, and content of vasogenic events. Some of these parameters allow prediction of prognosis of survival following head injury and optimisation of "CPP-guided therapy". In hydrocephalus CSF dynamic tests aid diagnosis and subsequent monitoring of shunt function.

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The Camino intracranial pressure device in clinical practice. Assessment in a 1000 cases.

J Dieguez, Martha Garcia, R M Rumbo … (2006)

Intracranial pressure (ICP) monitoring has become standard in the management of neurocritical patients. A variety of monitoring techniques and devices are available, each offering advantages and disadvantages. Analysis of large populations has never been performed. A prospective study was designed to evaluate the Camino fiberoptic intraparenchymal cerebral pressure monitor for complications and accuracy. Between 1992-2004 one thousand consecutive patients had a fiberoptic ICP monitor placed. The most frequent indication for monitoring was severe head injury (697 cases). The average duration of ICP monitoring was 184.6 +/- 94.3 hours; the range was 16-581 hours. Zero drift (range, -17 to 21 mm Hg; mean 7.3 +/- 5.1) was recorded after the devices were removed from 624 patients. Mechanical complications such as: breakage of the optical fiber (n = 17); dislocations of the fixation screw (n = 15) or the probe (n = 13); and failure of ICP recording for unknown reasons (n = 4) were found in 49 Camino devices. The Camino ICP sensor remains one of the most popular ICP monitoring devices for use in critical neurosurgical patients. The system offers reliable ICP measurements in an acceptable percentage of device complications and the advantage of in vivo recalibration. The incidence of technical complications was low and similar to others devices.

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Author and article information

Journal

Journal ID (nlm-ta): Biomed Eng Online

Journal ID (iso-abbrev): Biomed Eng Online

Title: BioMedical Engineering OnLine

Publisher: BioMed Central

ISSN (Electronic): 1475-925X

Publication date Collection: 2014

Publication date (Electronic): 28 January 2014

Volume: 13

Page: 7

Affiliations

[1 ]Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway

[2 ]Faculty of Medicine, University of Oslo, Oslo, Norway

Article

Publisher ID: 1475-925X-13-7

DOI: 10.1186/1475-925X-13-7

PMC ID: 3922657

PubMed ID: 24472296

SO-VID: c19bf065-1916-4322-af2f-66a018196852

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Baseline pressure errors (BPEs) extensively influence intracranial pressure scores: results of a prospective observational study

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Abstract

Background

Methods

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Conclusions

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Journal of Disability Research

Most cited references 21

A trial of intracranial-pressure monitoring in traumatic brain injury.

Monitoring and interpretation of intracranial pressure.

The Camino intracranial pressure device in clinical practice. Assessment in a 1000 cases.

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