Monitoring brain chemistry : Improving outcome?  Urban Ungerstedt, Prof. emeritus Karolinska institutet, Stockholm Nationa...
Assumptions about ”rescue and repair” of brain tissue <ul><li>Brain pathology is due to alterations in brain chemistry </l...
Micro- dialysis  catheter Oxygen  catheter Monitoring local brain chemistry Oxygen delivery Glucose delivery Brain cell  m...
The principle of microdialysis Blood  capillary Interstitial  fluid Cells
Instruments of microdialysis Brain
Billing – Cottage hospital (Santa Barbara) Laboratory Billing Software
Ischemia and/or mitochondrial damage Glucose Pyruvate Lactate Glucose Energy Oxygen Oxygen ATP Energy Lactate Lactate/Pyru...
Cell damage Oxygen Glucose Ca ++   molecules Glycero-phospho- lipids Phospholipases Glycerol Glycerol Ca ++  channel
Microdialysis biomarkers <ul><li>Glucose  </li></ul><ul><li>Lactate </li></ul><ul><li>Pyruvate </li></ul><ul><li>LPR (Lact...
Dead tissue Penumbra   – highly vulnerable Compressed – vulnerable ” Normal” tissue Different demands on intensive care! ’
Interventions normalizing tissue chemistry:  Penumbra vs Normal brain tissue 12 augusti 2011 Urban Ungerstedt Blood transf...
Interventions normalizing tissue chemistry:  Penumbra vs Normal brain tissue 12 augusti 2011 Urban Ungerstedt Lactate/Pyru...
ACA dx MCA sin 2004-09-06 2004-09-07 2004-09-08 2004-09-09 2004-09-10 2004-09-11 2004-09-12 2004-09-13 2004-09-14 2004-09-...
Demonstrating  patient cases in ICUpilot 12 augusti 2011 Urban Ungerstedt
We must rethink the outcome concept! <ul><li>Analysis of lactate, pyruvat and lactate/pyruvate ratio  tell us  how serious...
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Ungerstedt, Urban

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Ungerstedt, Urban

  1. 1. Monitoring brain chemistry : Improving outcome? Urban Ungerstedt, Prof. emeritus Karolinska institutet, Stockholm National Neurotrauma Symposium, Fort Lauderdale, July 13, 2011
  2. 2. Assumptions about ”rescue and repair” of brain tissue <ul><li>Brain pathology is due to alterations in brain chemistry </li></ul><ul><li>By monitoring ICP we may rescue the brain from global ischemia and herniation </li></ul><ul><li>By monitoring local chemistry we may improve the repair process and save brain tissue by: </li></ul><ul><ul><li>Improving capillary perfusion by drugs (adjusting CPP) or surgery (craniotomy, evacuating dead tissue) </li></ul></ul><ul><ul><li>Optimizing brain energy supply: Adjusting glucose and oxygen delivery </li></ul></ul><ul><ul><li>Optimizing temperaure: Normo- or hypothermia </li></ul></ul><ul><ul><li>Optimizing tissue survival: Neuroprotective drugs </li></ul></ul><ul><li>Saving brain tissue means a priori better outcome </li></ul>12 augusti 2011 Urban Ungerstedt
  3. 3. Micro- dialysis catheter Oxygen catheter Monitoring local brain chemistry Oxygen delivery Glucose delivery Brain cell metabolism
  4. 4. The principle of microdialysis Blood capillary Interstitial fluid Cells
  5. 5. Instruments of microdialysis Brain
  6. 6. Billing – Cottage hospital (Santa Barbara) Laboratory Billing Software
  7. 7. Ischemia and/or mitochondrial damage Glucose Pyruvate Lactate Glucose Energy Oxygen Oxygen ATP Energy Lactate Lactate/Pyruvate ADP ATP Citric Acid Cycle
  8. 8. Cell damage Oxygen Glucose Ca ++ molecules Glycero-phospho- lipids Phospholipases Glycerol Glycerol Ca ++ channel
  9. 9. Microdialysis biomarkers <ul><li>Glucose </li></ul><ul><li>Lactate </li></ul><ul><li>Pyruvate </li></ul><ul><li>LPR (Lactate/Pyruvate ratio) </li></ul><ul><li>Glycerol </li></ul><ul><li>Glutamate </li></ul><ul><li>Almost any other analyte </li></ul>12 augusti 2011 Urban Ungerstedt Off-line laboratory analysis Aerobic and anaerobic glucose metabolism Membrane decomposicion and energy failure
  10. 10. Dead tissue Penumbra – highly vulnerable Compressed – vulnerable ” Normal” tissue Different demands on intensive care! ’
  11. 11. Interventions normalizing tissue chemistry: Penumbra vs Normal brain tissue 12 augusti 2011 Urban Ungerstedt Blood transfusion 1999-01-08 1999-01-09 1999-01-10 1999-01-11 1999-01-12 00:00 12:00 00:00 12:00 00:00 12:00 00:00 0 10 20 30 40 Lactate/Pyruvate penumbra Lactate /Pyruvate normal 1999-01-08 1999-01-09 1999-01-10 1999-01-11 1999-01-12 00:00 12:00 00:00 12:00 00:00 12:00 00:00 0 10 20 30 40 CPP
  12. 12. Interventions normalizing tissue chemistry: Penumbra vs Normal brain tissue 12 augusti 2011 Urban Ungerstedt Lactate/Pyruvate penumbra 1999-01-08 1999-01-09 1999-01-10 1999-01-11 1999-01-12 00:00 12:00 00:00 12:00 00:00 12:00 00:00 0 10 20 30 40 Glycerol penumbra – cell damage Glycerol normal 1999-01-08 1999-01-09 1999-01-10 1999-01-11 1999-01-12 00:00 12:00 00:00 12:00 00:00 12:00 00:00 0 200 400 600 800 1000 1200
  13. 13. ACA dx MCA sin 2004-09-06 2004-09-07 2004-09-08 2004-09-09 2004-09-10 2004-09-11 2004-09-12 2004-09-13 2004-09-14 2004-09-15 00:00 00:00 00:00 00:00 00:00 10 20 30 40 La/py ratio 0 500 1000 Glycerol,  M 100 150 Flow velocity m/s Vasospasm after SAH
  14. 14. Demonstrating patient cases in ICUpilot 12 augusti 2011 Urban Ungerstedt
  15. 15. We must rethink the outcome concept! <ul><li>Analysis of lactate, pyruvat and lactate/pyruvate ratio tell us how serious the tissue energy crises is. </li></ul><ul><li>Analysis of glycerol tell us how much damage there is to cell membranes. </li></ul><ul><li>Multimodal monitoring over time tell us how successful we are in reversing pathology. </li></ul><ul><li>Reversing pathology = Improving tissue outcome. </li></ul>12 augusti 2011 Urban Ungerstedt

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