Neuromonitoring Techniques in the Neuro ICU:  Brain Tissue Oxygenation Shelly D. Timmons, MD, PhD, FACS, FAANS Director of...
Learning Objectives <ul><li>The attendee will: </li></ul><ul><ul><li>Be familiar with indications for use of brain tissue ...
Balanced Approach <ul><li>Following Guidelines </li></ul><ul><li>Tailored Therapy </li></ul>
TBI Treatment Goals <ul><li>Actions </li></ul><ul><li>Reduction of intracranial pressure </li></ul><ul><li>Maintenance of ...
ICP MAP CBF P bt O 2 Brain Temp Na Osm Plt PT PTT Hgb Hct ABG Gluc Microdialysis CPP SjvO 2 EEG ECOG Neurological Exam Ima...
<ul><li>Indicator of oxygen extraction by brain </li></ul><ul><li>Measures O 2  saturation in returning blood </li></ul><u...
Jugular Venous O 2  Saturation <ul><li>High S jv O 2  correlates with </li></ul><ul><ul><li>Hyperemia / High CBF </li></ul...
<ul><li>Xenon CT </li></ul><ul><li>PET </li></ul><ul><li>MRI </li></ul><ul><li>CBF Monitor </li></ul><ul><li>Future </li><...
Cerebral Blood Flow Monitor <ul><li>Absolute, real-time continuous perfusion  </li></ul><ul><li>Measured from 0 - 200 ml/1...
<ul><li>Current technology allows for focal measurements, not global </li></ul><ul><li>Not a stand-alone monitor but good ...
Brain Tissue Oxygenation P bt O 2 <ul><li>Measures interstitial brain tissue oxygenation (P bt O 2 )   in mm Hg and brain ...
A closed polarographic probe with reversible electrochemical reactions Brain Tissue Oxygenation P bt O 2
<ul><li>Oxygen Accuracy: </li></ul><ul><ul><li>P bt O 2  0-20 mmHg  accuracy is ± 2 mmHg </li></ul></ul><ul><ul><li>P bt O...
Insertion Technique <ul><li>Small Stab Incision </li></ul><ul><li>Small Drill Hole </li></ul><ul><li>Placement of Bolt </l...
Techniques <ul><li>ICP Parenchymal Monitor </li></ul><ul><ul><li>With Ventricular Drainage </li></ul></ul><ul><ul><ul><li>...
Brain Oxygen Monitoring Guidelines   2008 <ul><li>Level I </li></ul><ul><ul><li>Insufficient Data </li></ul></ul><ul><li>L...
Indications <ul><li>Severe TBI (GCS 3-8) </li></ul><ul><li>Blunt Vascular Injury </li></ul>
P bt O 2 <ul><li>Normal: 25-35 mmHg </li></ul><ul><li>Low P bt O 2  occurs frequently in the first 24 hours after injury <...
<ul><li>“ Since the first (mostly European) reports of continuous monitoring of P bt O 2  in humans, investigators have co...
P bt O 2  and Mortality <ul><li>Risk of death increases </li></ul><ul><ul><li>< 15 mmHg for 30 minutes </li></ul></ul><ul>...
P bt O 2  and Mortality <ul><li>Time with  </li></ul><ul><li>P bt O 2  < 10 mm Hg  </li></ul><ul><li>< 30 minutes  </li></...
Low P bt O 2  and Mortality <ul><li>Association with  increased mortality </li></ul><ul><ul><li>Increasing duration of tim...
Low P bt O 2  and Mortality <ul><li>Increased mortality with shorter time periods as P bt O 2  decreases </li></ul><ul><li...
Low P bt O 2  and Mortality <ul><li>Desaturations can occur even with acceptable ICP and CPP levels </li></ul><ul><li>Thes...
Low P bt O 2  Causes <ul><li>Several correctable causes of cerebral oxygen desaturations  </li></ul><ul><ul><li>Insufficie...
Techniques to Improve P bt O 2 <ul><li>Elevation of CPP </li></ul><ul><ul><li>Increases in Blood Volume, MAP </li></ul></u...
Techniques to Improve P bt O 2 <ul><li>Transfusion of Packed Red Blood Cells (PRBCs) </li></ul><ul><ul><li>Increases P bt ...
Techniques to Improve P bt O 2 <ul><li>Transfusion of Packed Red Blood Cells (PRBCs) </li></ul><ul><ul><li>Increases in P ...
Techniques to Improve P bt O 2 <ul><ul><li>Conflicting data exist on baseline P bt O 2  effects on improved P bt O 2 </li>...
Techniques to Improve P bt O 2 <ul><li>Increasing Ventilatory FiO 2  to supranormal levels (normobaric hyperoxia) can incr...
Techniques to Improve P bt O 2 <ul><li>Primary lung function can affect the cerebral oxygenation response to administratio...
Techniques to Improve P bt O 2 <ul><li>Decompressive Hemicraniectomy </li></ul>Stiefel MF, Heuer GG, Smith MJ, et al.  J N...
Relationship to CBF <ul><li>Correlation shown with Xenon CT, CT perfusion studies, and non-invasive monitoring </li></ul><...
Oxygen Diffusion  <ul><li>Impaired after brain injury  </li></ul><ul><ul><li>Perivascular edema </li></ul></ul><ul><ul><li...
Potential Problems <ul><li>Pitfalls </li></ul><ul><li>Catheters are stable </li></ul><ul><li>Factors affecting readings: <...
Assessing Physiology  of Secondary Injury <ul><li>“ Global” </li></ul><ul><ul><li>ICP </li></ul></ul><ul><ul><li>CPP </li>...
ICP MAP CBF P bt O 2 Brain Temp Na Osm Plt PT PTT Hgb Hct ABG Gluc Microdialysis CPP SjvO 2 EEG ECOG Neurological Exam Ima...
Future of Neuromonitoring <ul><li>Storage & Interpretation of Ever More Continuous Physiological Data </li></ul><ul><li>Mu...
TBI Advisor Evidence-Based Treatments  Interventions
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Timmons, Shelly

  1. 1. Neuromonitoring Techniques in the Neuro ICU: Brain Tissue Oxygenation Shelly D. Timmons, MD, PhD, FACS, FAANS Director of Neurotrauma Geisinger Health System July 17, 2011
  2. 2. Learning Objectives <ul><li>The attendee will: </li></ul><ul><ul><li>Be familiar with indications for use of brain tissue oxygenation in traumatic brain injury patients </li></ul></ul><ul><ul><li>Understand potential pitfalls and complications of brain tissue oxygenation monitoring </li></ul></ul><ul><ul><li>Understand commonly employed treatments for low brain tissue oxygenation </li></ul></ul>
  3. 3. Balanced Approach <ul><li>Following Guidelines </li></ul><ul><li>Tailored Therapy </li></ul>
  4. 4. TBI Treatment Goals <ul><li>Actions </li></ul><ul><li>Reduction of intracranial pressure </li></ul><ul><li>Maintenance of cerebral perfusion </li></ul><ul><li>Avoidance of Tissue Hypoxia </li></ul><ul><li>Goals </li></ul><ul><li>Prevention of Secondary Injury </li></ul><ul><li>Reduced Mortality </li></ul><ul><li>Improvements in Functional Outcome </li></ul>
  5. 5. ICP MAP CBF P bt O 2 Brain Temp Na Osm Plt PT PTT Hgb Hct ABG Gluc Microdialysis CPP SjvO 2 EEG ECOG Neurological Exam Imaging Operative Findings
  6. 6. <ul><li>Indicator of oxygen extraction by brain </li></ul><ul><li>Measures O 2 saturation in returning blood </li></ul><ul><ul><li>Compare with arterial O 2 saturation  Arteriovenous Oxygenation Difference (AVDO 2 ) </li></ul></ul><ul><ul><li>Used to assess CMRO 2 </li></ul></ul><ul><li>Variations are common from a variety of causes </li></ul><ul><li>Not commonly used—typically in clinical research centers </li></ul>Jugular Venous O 2 Saturation
  7. 7. Jugular Venous O 2 Saturation <ul><li>High S jv O 2 correlates with </li></ul><ul><ul><li>Hyperemia / High CBF </li></ul></ul><ul><ul><li>BUT also correlates with low oxygen extraction in the brain indicating ischemia </li></ul></ul><ul><ul><li>p bt O 2 is a more direct evaluation of relative cerebral ischemia </li></ul></ul>From: Anesth Analg. 2000 Mar;90(3):559-66 Schell RM, Cole DJ. Techniques may be complimentary
  8. 8. <ul><li>Xenon CT </li></ul><ul><li>PET </li></ul><ul><li>MRI </li></ul><ul><li>CBF Monitor </li></ul><ul><li>Future </li></ul><ul><ul><li>Near Infrared </li></ul></ul><ul><ul><li>Non-Invasive </li></ul></ul>Cerebral Blood Flow
  9. 9. Cerebral Blood Flow Monitor <ul><li>Absolute, real-time continuous perfusion </li></ul><ul><li>Measured from 0 - 200 ml/100g/min. </li></ul><ul><li>Thermal diffusion probe -- a minimally invasive (<1 mm diameter), flexible, interstitial catheter </li></ul>
  10. 10. <ul><li>Current technology allows for focal measurements, not global </li></ul><ul><li>Not a stand-alone monitor but good adjunct </li></ul><ul><li>pB t O 2 v alues can be manipulated through a variety of interventions </li></ul><ul><ul><li>Choosing appropriate interventions based upon underlying pathophysiology requires thorough knowledge and understanding of multiple parameters </li></ul></ul>Brain Tissue Oxygenation (pB t O 2 )
  11. 11. Brain Tissue Oxygenation P bt O 2 <ul><li>Measures interstitial brain tissue oxygenation (P bt O 2 ) in mm Hg and brain temperature (°C) </li></ul><ul><li>Probe inserted approximately 35mm below the dura into the white matter of the brain </li></ul><ul><li>P bt O 2 used in conjunction with current ICP/CPP monitoring methods </li></ul>
  12. 12. A closed polarographic probe with reversible electrochemical reactions Brain Tissue Oxygenation P bt O 2
  13. 13. <ul><li>Oxygen Accuracy: </li></ul><ul><ul><li>P bt O 2 0-20 mmHg accuracy is ± 2 mmHg </li></ul></ul><ul><ul><li>P bt O 2 21-50 mmHg accuracy is ± 10% </li></ul></ul><ul><ul><li>P bt O 2 51-150 mmHg accuracy is ± 13% </li></ul></ul><ul><li>Temperature Accuracy: ± 0.2 °C </li></ul>Brain Tissue Oxygenation P bt O 2
  14. 14. Insertion Technique <ul><li>Small Stab Incision </li></ul><ul><li>Small Drill Hole </li></ul><ul><li>Placement of Bolt </li></ul><ul><li>Zeroing of Catheters </li></ul><ul><li>Insertion of Catheters </li></ul><ul><ul><li>ICP </li></ul></ul><ul><ul><li>Brain Temperature / P bt O 2 </li></ul></ul>
  15. 15. Techniques <ul><li>ICP Parenchymal Monitor </li></ul><ul><ul><li>With Ventricular Drainage </li></ul></ul><ul><ul><ul><li>Advantages </li></ul></ul></ul><ul><ul><ul><ul><li>Allow for continuous CSF drainage and continuous ICP measurement </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allow for intermittent CSF drainage and continuous ICP measurement </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allow for fluid-coupled mechanism of ICP confirmation </li></ul></ul></ul></ul><ul><ul><li>Without Ventricular Drainage </li></ul></ul><ul><ul><ul><li>Advantages </li></ul></ul></ul><ul><ul><ul><ul><li>Lower Complication Rate </li></ul></ul></ul></ul>
  16. 16. Brain Oxygen Monitoring Guidelines 2008 <ul><li>Level I </li></ul><ul><ul><li>Insufficient Data </li></ul></ul><ul><li>Level II </li></ul><ul><ul><li>Insufficient Data </li></ul></ul><ul><li>Level III </li></ul><ul><ul><li>Jugular venous saturation (<50%) or brain tissue oxygen tension (<15 mm Hg) are treatment thresholds </li></ul></ul><ul><ul><li>Jugular venous saturation or brain tissue oxygen monitoring measure cerebral oxygenation </li></ul></ul>
  17. 17. Indications <ul><li>Severe TBI (GCS 3-8) </li></ul><ul><li>Blunt Vascular Injury </li></ul>
  18. 18. P bt O 2 <ul><li>Normal: 25-35 mmHg </li></ul><ul><li>Low P bt O 2 occurs frequently in the first 24 hours after injury </li></ul>Bardt TF, Unterberg AW, Hartl R, et al. Acta Neurochir 1998; 71:153–156 Dings J, Ja¨ger A, Meixensberger J, et al. Neurol Res 1998; 20(Suppl 1):S71–S75
  19. 19. <ul><li>“ Since the first (mostly European) reports of continuous monitoring of P bt O 2 in humans, investigators have consistently shown correlations of P bt O 2 values with clinical course and outcomes, and of effects on P bt O 2 by various treatment interventions…” </li></ul>Timmons, SD Crit Care Med . 2010 Sep;38(9 Suppl):S431-44. These effects may be independent of effects on ICP or CPP
  20. 20. P bt O 2 and Mortality <ul><li>Risk of death increases </li></ul><ul><ul><li>< 15 mmHg for 30 minutes </li></ul></ul><ul><ul><li>< 10 mmHg for 10 minutes </li></ul></ul><ul><li>P bt O 2 < 5 mmHg </li></ul><ul><ul><li>high mortality </li></ul></ul><ul><li>P bt O 2 < 2mmHg </li></ul><ul><ul><li>neuronal death </li></ul></ul>Bardt TF, Unterberg AW, Hartl R, et al. Acta Neurochir 1998; 71:153–156 N.B. Good outcomes are possible even with hypoxic episodes
  21. 21. P bt O 2 and Mortality <ul><li>Time with </li></ul><ul><li>P bt O 2 < 10 mm Hg </li></ul><ul><li>< 30 minutes </li></ul><ul><li>vs. </li></ul><ul><li>> 30 minutes </li></ul>Bardt et al. 1998 6-Month GOS 35 Severe TBI Pts.
  22. 22. Low P bt O 2 and Mortality <ul><li>Association with increased mortality </li></ul><ul><ul><li>Increasing duration of time < 15 </li></ul></ul><ul><ul><li>Any value < 6 also </li></ul></ul>Valadka AB, Gopinath SP, Contant CF, et al. Crit Care Med 1998; 26:1576–1581 Dings J, Ja¨ger A, Meixensberger J, et al. Neurol Res 1998; 20 (Suppl 1):S71–S75
  23. 23. Low P bt O 2 and Mortality <ul><li>Increased mortality with shorter time periods as P bt O 2 decreases </li></ul><ul><li>50% Mortality </li></ul><ul><li><5 30 minutes </li></ul><ul><li><10 105 minutes </li></ul><ul><li><15 240 minutes </li></ul>6-Month GOS 101 Severe TBI Patients Van den Brink et al. 2000 Effects of obliterated cisterns
  24. 24. Low P bt O 2 and Mortality <ul><li>Desaturations can occur even with acceptable ICP and CPP levels </li></ul><ul><li>These associated with higher mortality </li></ul><ul><li>Targeted therapies can improve outcome, even in the face of normal ICP/CPP </li></ul><ul><li>Additional benefit in the diffuse injury group </li></ul>Stiefel MF, Spiotta A, Gracia VH, et al. J Neurosurg 2005; 103:805–811 Stiefel MF, Udoetuk JD, Spiotta AM, et al. J Neurosurg 2006; 105:568–575 Narotam PK, Morrison JF, Nathoo N J Neurosurg 2009; 111:672–682
  25. 25. Low P bt O 2 Causes <ul><li>Several correctable causes of cerebral oxygen desaturations </li></ul><ul><ul><li>Insufficient CPP </li></ul></ul><ul><ul><li>Vasospasm </li></ul></ul><ul><ul><li>Pulmonary atelectasis resulting in hypoxemia </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Premature interruption of ICP-controlling medications </li></ul></ul>Artru F, Jourdan C, Perret-Liaudet A, et al. Neurol Res 1998; 20:S48–S51
  26. 26. Techniques to Improve P bt O 2 <ul><li>Elevation of CPP </li></ul><ul><ul><li>Increases in Blood Volume, MAP </li></ul></ul><ul><ul><li>Decreases in ICP </li></ul></ul><ul><li>Hypertonic saline </li></ul><ul><li>Pressors </li></ul><ul><li>Sedatives </li></ul><ul><li>Barbiturates </li></ul><ul><ul><li>Independent of fx on ICP  </li></ul></ul><ul><ul><li>cerebral metabolism </li></ul></ul>Artru F, Jourdan C, Perret-Liaudet A, et al. Neurol Res 1998; 20:S48–S51 Cormio M, Gopinath SP, Valadka AB, et al. J Neurotrauma 1999; 16:927–936 Johnston AJ, Steiner LA, Coles JP, et al. Crit Care Med 2005; 33:189–195 Oddo M, Levine JM, Frangos S, et al. J Neurol Neurosurg Psych 2009; 80:916–920 Narotam PK, Morrison JF, Nathoo N J Neurosurg 2009; 111:672–682 Kiening KL, Ha¨rtl R, Unterberg AW, et al. Neurol Res 1997;19:233–240 Imberti R, Fuardo M, Bellinzona G, et al. J Neurosurg 2005; 102:455–459 Thorat JD, Wang EC, Lee KK, et al. J Clin Neurosci 2008;15: 143–148 Chen HI, Malhotra NR, Oddo M, et al. Neurosurgery 2008;63:880–997
  27. 27. Techniques to Improve P bt O 2 <ul><li>Transfusion of Packed Red Blood Cells (PRBCs) </li></ul><ul><ul><li>Increases P bt O 2 </li></ul></ul><ul><ul><li>Improved oxygen-carrying capacity of the blood </li></ul></ul><ul><ul><li>Effect more prominent in the presence of higher lactate/pyruvate ratios (mitochondrial dysfunction) </li></ul></ul>Smith MJ, Stiefel MF, Magge S, et al. Crit Care Med 2005; 33:1104–1108 Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A, et al. Intensive Care Med 2006; 32: 1733–1740 Zygun DA, Nortje J, Hutchinson PJ, et al. Crit Care Med 2009; 37:1074–1078
  28. 28. Techniques to Improve P bt O 2 <ul><li>Transfusion of Packed Red Blood Cells (PRBCs) </li></ul><ul><ul><li>Increases in P bt O 2 independent of </li></ul></ul><ul><ul><ul><li>CPP changes </li></ul></ul></ul><ul><ul><ul><li>Cardiac index </li></ul></ul></ul><ul><ul><ul><li>Peripheral oxygen saturation </li></ul></ul></ul><ul><ul><ul><li>FiO 2 </li></ul></ul></ul>Artru F, Jourdan C, Perret-Liaudet A, et al. Neurol Res 1998; 20:S48–S51 Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A, et al. Intensive Care Med 2006; 32: 1733–1740 Smith MJ, Stiefel MF, Magge S, et al. Crit Care Med 2005; 33:1104–1108
  29. 29. Techniques to Improve P bt O 2 <ul><ul><li>Conflicting data exist on baseline P bt O 2 effects on improved P bt O 2 </li></ul></ul><ul><li>Age of the transfused blood products may affect efficacy (storage > 19 days) </li></ul>Leal-Noval SR, Rincon-Ferrari MD, Marin-Niebla A, et al. Intensive Care Med 2006; 32: 1733–1740 Zygun DA, Nortje J, Hutchinson PJ, et al. Crit Care Med 2009; 37:1074–1078 Weigh well-documented risks vs. the potential benefit of protection from secondary injury
  30. 30. Techniques to Improve P bt O 2 <ul><li>Increasing Ventilatory FiO 2 to supranormal levels (normobaric hyperoxia) can increase P bt O 2 </li></ul><ul><li>BUT </li></ul><ul><li>May not lead to better CBF or cerebral metabolic rate of oxygen consumption </li></ul>Tolias CM, Reinert M, Seiler R, et al. J Neurosurg 2004; 101: 435–444 Nortje J, Coles JP, Timofeev I, et al. Crit Care Med 2008; 36:273–280 Diringer MN, Aiyagari V, Zazulia AR, et al. J Neurosurg 2007; 106: 526–529
  31. 31. Techniques to Improve P bt O 2 <ul><li>Primary lung function can affect the cerebral oxygenation response to administration of hyperoxic challenges. </li></ul><ul><li>P a O 2 /FiO 2 ratios of 200–250 are associated with decreased cerebral oxygenation responsiveness </li></ul><ul><li>Important to determine the pulmonary status </li></ul><ul><ul><li>Monitoring of P a O 2 /FiO 2 ratios </li></ul></ul><ul><ul><li>Early diagnosis of ventilator-acquired pneumonia </li></ul></ul>Rockswold GL, Solid CA, Paredes-Andrade E, et al. Neurosurg 2009; 65:1035–1042 Rosenthal G, Hemphill JC, Sorani M, et al. Crit Care Med 2008 Jun; 36:1917–1924
  32. 32. Techniques to Improve P bt O 2 <ul><li>Decompressive Hemicraniectomy </li></ul>Stiefel MF, Heuer GG, Smith MJ, et al. J Neurosurg 2004; 101:241–247 Ho CL, Wang CM, Lee KK, et al. J Neurosurg 2008; 108:943–949 Used w/ permission: William Coplin, M.D. Contralateral to Surgical Site
  33. 33. Relationship to CBF <ul><li>Correlation shown with Xenon CT, CT perfusion studies, and non-invasive monitoring </li></ul><ul><li>Limitations in measurement ability </li></ul><ul><li>Non-correlated variations also occur </li></ul><ul><ul><li>Changing oxygen demands and delivery </li></ul></ul><ul><ul><li>CO 2 reactivity </li></ul></ul><ul><ul><li>Coupling/uncoupling of cerebral metabolism to CBF in patients with brain pathology </li></ul></ul>
  34. 34. Oxygen Diffusion <ul><li>Impaired after brain injury </li></ul><ul><ul><li>Perivascular edema </li></ul></ul><ul><ul><li>Endothelial edema </li></ul></ul><ul><ul><li>Microvascular collapse </li></ul></ul><ul><li>Resulting in </li></ul><ul><ul><li>Impaired oxygen extraction </li></ul></ul><ul><ul><ul><li>Even with hypoperfusion (Extraction should be higher) </li></ul></ul></ul>Low P bt O 2 may be more closely related to impaired oxygen diffusion rather than oxygen delivery or metabolism. Diringer MN, Aiyagari V, Zazulia AR, et al. J Neurosurg 2007; 106: 526–529 Menon D, Coles JP, Gupta AK, et al. Crit Care Med 2004 Jun; 32: 1384–1390 Rockswold SB, Rockswold GL, Zaun DA, et al. J Neurosurg 2010; 112:1080–1094 Mannitol
  35. 35. Potential Problems <ul><li>Pitfalls </li></ul><ul><li>Catheters are stable </li></ul><ul><li>Factors affecting readings: </li></ul><ul><ul><li>Calibration over first two hours </li></ul></ul><ul><ul><li>Dislodgement of catheter </li></ul></ul><ul><ul><li>Catheter breakage </li></ul></ul><ul><li>Complications </li></ul><ul><li>Complication rates are low </li></ul><ul><ul><li>Hematoma </li></ul></ul><ul><ul><li>Infection </li></ul></ul>Van Santbrink H, Maas AIR, Avezaat CJJ Neurosurgery 1996; 38: 21–31 Dings J, Meixensberger J, Roosen K J Neurological Res 1997; 19:1–5 Van den Brink WA, Van Santbrink H, Steyerberg EW, et al. Neurosurgery 2000; 46: 868–878 Anderson, RCE, Kan P, Klimo P, et al. J Neurosurg (Pediatrics 2) 101:53–58, 2004
  36. 36. Assessing Physiology of Secondary Injury <ul><li>“ Global” </li></ul><ul><ul><li>ICP </li></ul></ul><ul><ul><li>CPP </li></ul></ul><ul><ul><li>CBF </li></ul></ul><ul><ul><li>S jv O 2 </li></ul></ul><ul><li>“ Regional” </li></ul><ul><ul><li>P bt O 2 </li></ul></ul><ul><ul><li>Microdialysis </li></ul></ul><ul><ul><li>PET </li></ul></ul><ul><ul><li>ECOG </li></ul></ul>
  37. 37. ICP MAP CBF P bt O 2 Brain Temp Na Osm Plt PT PTT Hgb Hct ABG Gluc Microdialysis CPP SjvO 2 EEG ECOG Neurological Exam Imaging Operative Findings
  38. 38. Future of Neuromonitoring <ul><li>Storage & Interpretation of Ever More Continuous Physiological Data </li></ul><ul><li>Multimodality Monitoring </li></ul><ul><li>Linkage to Events </li></ul><ul><ul><li>Movements/Transport </li></ul></ul><ul><ul><li>Imaging </li></ul></ul><ul><ul><li>Surgeries and Other Procedures </li></ul></ul><ul><ul><li>Family Visits </li></ul></ul><ul><ul><li>Nursing Care </li></ul></ul><ul><ul><ul><li>Bathing/Turning/Suctioning </li></ul></ul></ul><ul><ul><li>Drug Administration </li></ul></ul><ul><ul><li>O 2 Desaturations </li></ul></ul><ul><ul><li>Lab Derangements </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><li>Linkage to Examination </li></ul><ul><ul><li>GCS </li></ul></ul><ul><ul><li>Pupils </li></ul></ul><ul><li>Ultimately </li></ul><ul><li>Linkage to Outcomes Will Aid in Research and More Evidence-Driven Approaches to TBI </li></ul>Not Just ICP Control But Also Metabolism-Driven Therapy
  39. 39. TBI Advisor Evidence-Based Treatments  Interventions
  40. 40. Thank You [email_address]

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