Myburgh, John — Raised ICP: Keeping a Lid on It
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Myburgh, John — Raised ICP: Keeping a Lid on It

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John Myburgh on the misunderstood craniectomy. The management of raised ICP and what we do when our options run out.

John Myburgh on the misunderstood craniectomy. The management of raised ICP and what we do when our options run out.

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Myburgh, John — Raised ICP: Keeping a Lid on It Myburgh, John — Raised ICP: Keeping a Lid on It Presentation Transcript

  • Raised intracranial pressure: keeping a lid on it UNSW John Myburgh MBBCh PhD FCICM The George Institute for Global Health St George Clinical School, University of New South Wales
  • P(mmHg) V (ml) 1783, 1824 Monro-Kelly doctrine Intracranial volume remains constant at any given time
  • Bryan Jennett Douglas Miller Larry Marshall 1978 1979 1980 Fearnside: Br J Neurosurg 1992
  • Inflammatory modulation Bayir: Crit Care Med 2003
  • Neuroprotective trials Maas: Neurosurgery 1999 HIT I (n=351) HIT II (n=852) HIT III (n=123) PEGSOD (n=463) Tirilizad (n=1128) Triamcinolone (n=396) HIT II tSAH Tirilizad tSAH Triamcinolone GCS 8 +focal lesion Neuroprotective agents All steroids mean = 435
  • Rat / human model 20th century Take a young male rat. Infuse alcohol or speed 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 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.
  • Randy Chesnut Nino Stocchetti Andrew Maas www.braintrauma.org 2001, 2003, 2007
  • Critical pathway BTF Guidelines 1st, 2nd editions
  • Tier 1 Critical pathway: proposed Tier 2 Tier 3 Low dose mannitol Normothermia Decompressive craniectomy Induced hypothermia Neuromuscular blockade High dose mannitol Hypertonic saline Mild hypothermia (35-37) BTF Guidelines Working Group: 2009
  • 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.
  • Comparative data ATBIS GCS<9 SAFE TBI GCS<9 (Albumin) SAFE TBI GCS<9 (Saline) n 363 160 158 Inception period 2000-2001 2001-2003 2001-2003 12-month mortality: n/N (%) 105/299 (35.1) 61/153 (39.9) 32/149 (21.5) Myburgh J Trauma: 2008
  • Decompressive craniectomy Indication Age Diffuse vs mass lesion Traumatic vs non-traumatic Timing Pre-emptive Rescue Trigger CT / clinical ICP Technique Bifrontal vs unilateral Dura open vs closed Outcome Physiological Death / functional outcome
  • Honeybul: Brian inj 2013
  • Jiang:J Neurotrauma: 2005 Multicentred RCT, blinded outcome adjudication 1998 – 2001 n=486 Age < 70 Clinical / CT triggers for decompression Primary outcome: 6m GOS Standard Limited
  • Jiang:J Neurotrauma: 2005 GR / MD SD / PVS Dead 0 10 20 30 40 50 Standard DC (n=241)) Limited DC (n=245) 6m GOS % 0 10 20 30 40 50 Day ICP(mmHg) Pre DC 1 day 3 days 7 days Standard DC (n=36) Limited DC (n=47) p=0.03
  • Cooper: New Eng J Med 2011 Multicentred RCT, blinded outcome adjudication 2002-2011 N=155 (age <60) Age < 60; < 72h post injury CT trigger: Diffuse injury ICP trigger: >20 mmHg Primary outcome: 6m GOS vs Medical therapy
  • Cooper: New Eng J Med 2011 Unfavourable Favourable 70% 51% OR: 2.21 95%CI 1.14 to 4.26; P=0.02
  • www.rescueicp.com Multi-centre RCT, blinded outcome adjudication 366/400 patients recruited Age 18-65 ICP>25 mmHg Refractory to medical therapy (2nd tier) Included evacuated mass lesions Clinically directed decompression Primary outcome: Discharge + 6m GOSE
  • Honeybul: Brian inj 2013 Decompression for TBI Survivors with unfavourable outcomes Survivors with favourable outcomes Survivors with favourable outcomes
  • Honeybul: Brian inj 2013
  • Middle cerebral artery infarction Age limited: <60y Time limited: < 48 hours Co-morbidity / non-dominant hemisphere DECIMAL: n=38 (Germany) DESTINY: n=32 (France) HAMLET: n=39 (Netherlands) Hofmeijer: Lancet 2009
  • Middle cerebral artery infarction Age limited: >60y Time limited: < 48 hours Low co-morbidity / non-dominant hemisphere Juttler: NEJM 2014
  • Honeybul: Brian inj 2013 Decompression for non-TBI Survivors with unfavourable outcomes Survivors with favourable outcomes
  • Does Intensive Care improve outcome from TBI?
  • Chesnut: NEJM 2012 Multi-centred RCT, blinded outcome adjudication 2008-2011 N=324 Age >13 <60 GCS<9 , < 48h post injury Pressure/monitoring: ICP >20 mmHg + 3-tiered protocol Imaging/clinical exam: 3-tiered protocol Primary outcome: composite functional outcome 6m
  • Chesnut: NEJM 2012 ICP monitoring group Imaging/exam group P=0.60 ICP (n=157) ICE (n=167) OR (95%CI) p CFOS 56 (22-37) 53 (21-76) 1.09 (0.74 to 1.58) 0.49 Death 56/144 (39%) 67 (41%) 1.10 (0.77 to 1.57) 0.60
  • T H Huxley 1825 - 1895 m “That the great tragedy of Science is the slaying of a beautiful hypothesis with an ugly fact”
  • Some concluding thoughts 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
  • Some concluding thoughts Beware the therapeutic imperative to do what we can… … and not what we should