Andrew Udy talks about Brain Tissue Oxygen Monitoring: It’s Not What You’ve Got It’s What You Do With It The BONANZA Trial Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail! More on BONANZA here More on BOOST3 here

1. BONANZA: IT’S
NOT WHAT YOU’VE
GOT, IT’S WHAT
YOU DO WITH IT
ANDREW UDY

2. DISCLOSURES
UNRESTICTED IN-KIND RCT SUPPORT
(MONITORS AND CONSUMABLES) FROM
INTEGRA LIFESCIENCES INC.

4. ICP

5. N=324
Severe TBI
BOLIVIA &
ECUADOR

11. Control TBI
PbtO2

12. Control TBI
Rodriguez-Baeza, et al Anat Record 1998;252:176-184
Rodriguez-Baeza, et al Anat Record 2003;273A:583-593

15. Scenario Tier Task# Task
ICP
Only
ICP+
PbtO2
B
1
1 Adjust head of bed to lower ICP 61 44
2 Ensure temperature < 38 72 33
3 Adjust sedation and analgesia 324 181
4 Adjust ventilation to obtain PaCO2 between 35-40 mmHg 38 10
5 CSF drainage 165 59
6 Standard dose mannitol (0.25 – 1.0 g/kg) 63 23
7 Hypertonic saline 70 26
2
1 Adjust ventilation to lower PaCO2 to 32-35 mmHg. 9 5
2
High dose mannitol (>1g/kg), or higher frequency of standard
dose
6 6
3 Repeat CT – look for increased size of intracranial mass lesions 14 7
4 Treat surgically remediable lesions with craniotomy 0 1
5 Adjust temperature to 35 – 37 °C 4 4
3
1 Pentobarbital coma 1 0
2 Decompressive craniectomy 3 0
3 Adjust Temperature to 32 – 34.5 °C 1 0
4 Neuromuscular paralysis 8 2

16. PbtO2

17. BONANZA
BRAIN OXYGEN
NEUROMONNITORING
IN AUSTRALIA AND
NEW ZEALAND
ASSESSMENT

18. Adult Severe TBI (GCS 3-8 + abnormal CT)*
ICP monitoring deemed necessary
ICP only
available to
clinicians
PbtO2 & ICP
available to
clinicians
GOSE at 6-months
Minimum 48-hours PbtO2
monitoring. Discontinue if:
obeying commands, ICP
monitor removed, ICU
Discharge, or death.
Duration of ICP monitoring
determined by clinical
team.
Ancillary
interventions
and
general
management
as
per
local
guidelines
and
policy.

20. FiO2
(>0.3)
CPP
(70-80 mmHg)
PaCO2
(45-50 mmHg)
Hb
(> 90 g/L)
PbtO2

22. The ICU-ROX Investigators. NEJM, 2019; DOI: 10.1056/NEJMoa1903297

25. Conclusions
There is limited evidence for a significant functional
outcome benefit from ICP monitoring and ICP-based
interventions alone.
PbtO2 monitoring may offer a way to optimise the
neuronal environment for recovery.
Key therapeutic interventions:
- Optimal CBF (increased CPP / PaCO2)
- Greater O2 delivery (Hb)
- Reversal of diffusion hypoxia