Using microdialysis for clinical decisions in head injury


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World Neurosurgical Congress (WFNS), Boston, 2009

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  • Στην πε΄ριληψη έχετε γράψει 16 άτομα, ενώ εδώ μιλάτε για 18. Επειδή όλα τα υπόλοιπα έχουν βασιστεί σε αυτό καλύτερα να θεωρηθεί λάθος τυπογραφικό της περίληψης.Ίσως να πρέπεις να υπενθυμίσεις ΄το προφανές ότι δηλαδή ο διαχωρισμός σε ομάδες είναι retrospective και απλά για λόγους κατηγοριοποίησης.
  • Using microdialysis for clinical decisions in head injury

    1. 1. Clinical decisions based on microdialysisdatA in severe head injury<br />P.G.Papanikolaou, E.Papadopoulos, A.Markellos, K.Barkas, S.Stamatiou, A.Venetikidis, N.Papageorgiou, M.Fratzoglou, E.Chatzidakis, T.Kyriakou, T.S. Paleologos, K.Kazdaglis<br />Neurosurgical Department,<br />General Hospital of Nikea - Piraeus, Athens, Greece<br />
    2. 2. NOTHING TO DISCLOSE<br />
    3. 3. Οur experience<br /> Multimodal neuromonitoring in TBI patients using intraparenchymal brain catheters<br />Twist hand drill burr hole<br />Single same burr hole 5.3 mm<br />3 – lumen cranial bolt (LICOX)<br />ICP, PtiO2, microdialysis<br />
    4. 4. Treatment strategies<br />CPP targeted therapy<br /> - CPP &gt; 60 mm Hg<br /> - ICP &lt; 20 mm Hg<br /> - PtiO2 &gt; 20 mm Hg<br /> - L / P ≤ 25 <br />
    5. 5. Catheter’s tip<br />
    6. 6. What about microdialysis?<br /><ul><li>Not officially recommended as a clinical tool in TBI</li></ul>Microdialysis only for research<br />
    7. 7. Some centers favour it<br />and not only in<br />Hillered L, Vespa PM, Hovda DA.Translational neurochemical research in acute human brain injury: the current status and potential future for cerebral microdialysis.J Neurotrauma. 2005 Jan;22(1):3-41.<br />
    8. 8. Our center’s opinion<br />Clinical decisions based on microdialysisdata -Lactate to Pyruvateconcetrations’ ratio (L/P) - in severe head injury:<br />Treatment protocol of patients with peaks of intracranial hypertension up to 30 mmHg (“group A”)<br />Evaluation of success and duration of thiopenthaladministration (“group B”)<br />Decision for evacuation or not of “border-line” sized hematomas (“group C”)<br />
    9. 9.
    10. 10.
    11. 11. Group A<br />6 patients<br />episodes of intracranial hypertension up to 30mmHg<br />without significant change of the L/P ratio<br />Decision to treat with mannitol only or to proceed to second tier therapy with barbiturates<br />
    12. 12. Group A : Sporadic ICP elevations up to 30mmHg – just sedation and mannitol or something more aggressive ? <br />
    13. 13. Group B<br />6 patients<br />refractory intracranial hypertension<br />treated by barbiturates<br />L/P ratio was the main criteria for evaluation and duration of the treatment<br />
    14. 14. Group B : Conservative treatment. Barbiturate therapy for refractory intracranial hypertension. Evaluation of continuation of barbiturate induced coma<br />
    15. 15. Normalization of L/P before ICP<br />
    16. 16. Discharge CT scan<br />GOS 5 at 6 months<br />
    17. 17. Group C<br />6 patients<br />intracranial hematoma initially treated conservatively<br />L/P ratio in association with ICP determined the decision for a surgical evacuation<br />
    18. 18. Group C : 59 yrs, female Evacuation or not?<br />
    19. 19. Based on values of L/P&lt;25 : conservative treatment<br />
    20. 20. CT scan at two months (discharge)<br />GOS 4 at 6 months<br />
    21. 21. GOS<br />
    22. 22. Handicaps<br />Difficulty of insertion of the catheter via the 3/lumen bolt<br />Measurement frequency<br />ICU personnel deficiency<br />done by N/S residents<br />Lack of automatic data registration<br />National health system structure : patients -> ICU somewhere else<br />Hospital and social insurance managers not so helpful<br />
    23. 23. Conclusions<br />Multimodal neuromonitoring using brain catheters seems to be safe, reliable and useful tool<br />Data provided by microdialysis seems to be helpful taking appropriate clinical decisions<br />Especially useful in barbiturate therapy<br />
    24. 24. References<br />1.Poca MA et al. Percutaneous implantation of cerebral microdialysis catheters by twist-drill craniostomy in neurocritical patients: description of the technique and results of a feasibility study in 97 patients. J Neurotrauma. 2006 Oct;23(10):1510-7.<br />2. Tisdall MM et al Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006 Jul;97(1):18-25. Epub 2006 May 12<br />3. Hutchinson PJ. Microdialysis in traumatic brain injury--methodology and pathophysiology. ActaNeurochir Suppl. 2005;95:441-5<br />4. Martins RS et al. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. 2003 Aug;60(2):98-104<br />5. Sarrafzadeh AS et al. Detection of secondary insults by brain tissue pO2 and bedside microdialysis in severe head injury. Acta Neurochir Suppl. 2002;81:319-21.<br />6. Stahl N et al. Intracerebral microdialysis and bedside biochemical analysis in patients with fatal traumatic brain lesions. ActaAnaesthesiol Scand. 2001 Sep;45(8):977-85.<br />7. Hecimovic I et al. Intracranial infection after missile brain wound: 15 war cases. Zentralbl Neurochir. 2000;61(2):95-102.<br />8. Goodman JC et al. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients. J Neurotrauma. 1996 Oct;13(10):549-56.<br />9. Brain Trauma Foundation Guidelines 2007. J Neurotrauma2007;24 Suppl1:S91-5<br />10. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flowMonitoring.Intensive Care Med (2007) 33:1263–1271<br />11. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. II. Cerebral oxygenation monitoring and microdialysis. Intensive Care Med (2007) 33:1322–1328<br />