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.

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

  1. 1. 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
  2. 2. P(mmHg) V (ml) 1783, 1824 Monro-Kelly doctrine Intracranial volume remains constant at any given time
  3. 3. Bryan Jennett Douglas Miller Larry Marshall 1978 1979 1980 Fearnside: Br J Neurosurg 1992
  4. 4. Inflammatory modulation Bayir: Crit Care Med 2003
  5. 5. 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
  6. 6. 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.
  7. 7. Randy Chesnut Nino Stocchetti Andrew Maas www.braintrauma.org 2001, 2003, 2007
  8. 8. Critical pathway BTF Guidelines 1st, 2nd editions
  9. 9. 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
  10. 10. 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.
  11. 11. 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
  12. 12. 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
  13. 13. Honeybul: Brian inj 2013
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Cooper: New Eng J Med 2011 Unfavourable Favourable 70% 51% OR: 2.21 95%CI 1.14 to 4.26; P=0.02
  18. 18. 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
  19. 19. Honeybul: Brian inj 2013 Decompression for TBI Survivors with unfavourable outcomes Survivors with favourable outcomes Survivors with favourable outcomes
  20. 20. Honeybul: Brian inj 2013
  21. 21. 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
  22. 22. Middle cerebral artery infarction Age limited: >60y Time limited: < 48 hours Low co-morbidity / non-dominant hemisphere Juttler: NEJM 2014
  23. 23. Honeybul: Brian inj 2013 Decompression for non-TBI Survivors with unfavourable outcomes Survivors with favourable outcomes
  24. 24. Does Intensive Care improve outcome from TBI?
  25. 25. 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
  26. 26. 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
  27. 27. T H Huxley 1825 - 1895 m “That the great tragedy of Science is the slaying of a beautiful hypothesis with an ugly fact”
  28. 28. 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
  29. 29. Some concluding thoughts Beware the therapeutic imperative to do what we can… … and not what we should

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