NORMAL BLOOD PRESSURE OR

HYPERTENSIVE THERAPY
IN SEVERE TBI

I Putu Pramana Suarjaya

Department of Anesthesiology and Intensive Therapy

Sanglah General Hospital
Faculty of Medicine University of Udayana
Outline

 Severe TBI
 Blood Pressure Management In Severe TBI
 Blood Pressure Treshold

 Optimal CPP
Blood Pressure Management in
Severe TBI
 Cerebral hemodynamics is an extremely
complex interplay between the CBF, CBV, ICP
and a host of other factors that affect these
variables leading to a worsened outcome and
a proportionally high morbidity and mortality
 Although among all the variables the CPP has
been addressed the most;

 CBF is determined by both the CPP and

cerebrovascular resistance (CVR) and is
expressed as CBF = CPP/CVR
 PaO2, PaCO2, PH,CMRO2 and glucose affect
both the CBF and the CVR
 CPP value alone does not reflect
cerebral circulation, as it is also highly
dependent on the blood volume
status and the use of vasopressors
and on the hyperadrenergic stress.
 Hemodynamic Consequences of
Rigid Cranium

FIGURE 2 Hemodynamic consequences or the brain enclosed in the rigid dura/cranium. ΔPc ,
transcapillary hydrostatic capillary pressure: ΔΡonc transcapillary oncotic pressure: PA the arterial inflow
pressure: Q, cerebral blood flow; RA arterial precapillary resitance; RV venular resistance, ΔΡout
transvascular pressure retrogradely to the subdural venous collapse(R out); Pv, is extracranial venous
pressure. For details, see text. Reproduced from Ref. (3), with permission.
 A Effects of increase in B Effects of increase in
MAP on ICP MAP on ICP
Intracranial pressure (mmHg)

Intracranial pressure (mmHg)

50 50
40 40

elevated Blood
Pressure
Baseline
Elevated
Pressure

Blood
30 Blood 30

Pressure
Baseline

Blood pressure
Elevated
20 20

Blood pressure
Baseline
Baseline
10 10
0 0
2h 2h 5hr 5hr
rs Endotoxin rs s
(Steady s
Before After Endotoxin state)

Effects of an increase in mean arterial blood pressure of 30 mmHg, by

intravenous of dobutamin and angiotensin II, on intracranial pressure
(ICP) in the cat. (A) ICP with intact blood-brain barrier (BBB). (B) ICP
after disruption of the BBB with intrathecal endotoxin infusion
In Physiological Condition

 with normal autoregulatory response,

 Increase in MAP is beneficial as it brings
about a reduction in ICP owing to the
compensatory vasoconstriction mediated by
the autoregulatory response
In TBI patients

 When autoregulatory response is

impaired, the lower limit of autoregulation
has been shifted to the right and thus
perhaps would derive some benefit if the
MAP is engineered and kept at a level
above the normal range

Baguley IJ, Nicholls JL, Felmingham KL, Crooks J, Gurka JA, Wade LD.
Dysautonomia after traumatic brain injury: a forgotten syndrome? J Neurol
Neurosurg Psychiatry. 1999;67(1):39–43.
In experimental TBI

 Compensatory cerebral vasodilation

in response to hypotension,
hypoxemia and acute anemia is
impaired

Lewelt W, Jenkins LW, Miller JD. Effects of experimental fluid-percussion injury of

the brain on cerebrovascular reactivity to hypoxia and to hypercapnia.
J Neurosurg. 1982;56(3):332–8.
PERFUSION IN PENUMBRA ZONE

 Penumbra zone, is hypoxic but not dead

 Has the potential to survive
 Measures to improve oxygenation expected
to improve outcome.
 Penumbra zone most likely lacks myogenic
response (and autoregulation)
on admission

 Both SBP ≤ 90 mmHg and hypoxemia ≤60

mmHg substantially increase the risk of
unfavorable outcomes
Lower limit of the
autoregulatory curve in TBI

 may be closer to 70 mmHg rather than 50

mmHg .
 the lower limit of autoregulation indicates
that this is the point at which the CBF starts
to decrease rather than the point at which
ischemia ensues
Carney N, Totten AM, O’Reilly C, Ullman J.S, Hawryluk GWJ, Bell
MJ.Neurosurgery 0:1–10, 2016
Table 3. Updated Recommendations: Tresholdsa,b
Topic Recommendations
Blood pressure tresholds Level III
 
  Maintaining SBP at ≥ 100 mm Hg for patients 50 to 69 years old or at ≥ 110 mm Hg or above for patients 15 to 49 or
>70 years old may be considered to decrease mortality and improve outcomes.
 
Intracranial pressure Level IIB
tresholds  
  Treating ICP > 22 mm Hg is recommended because values above this level are associated with increased mortality
 
  Level III
 
  A combination of ICP values and clinical and brain CT findings may be used to make management decisions.
 
  *The committee is aware that the results of the RESCUEicp trial 2 were released after the completion of these
Guidelines. The results of this trial may affect these recommendations and may need to be considered by treating
physicians and other users of these Guidelines. We intend to update these recommendations if needed. Updates will
be available at https://braintrauma.org/coma/guidelines
Cerebral perfusion Level IIB
pressure thresholds  
 
  The recommended target CPP value for survival and favorable outcomes is between б0 and 70 mm Hg. Whether 60 or
70 mm Hg is the minimum optimal CPP threshold is unclear and may depend upon the autoregulatory status of the
patient.
 
  Level III
 
  Avoiding aggressive attempts to maintain CPP >70 mm Hg with fluids and pressors may be considered because of the
risk of adult respiratory failure
Blood Pressure thresholds

 Level III
 Maintaining SBP at $100 mm Hg for patients
50 to 69 years old
 or at $110 mm Hg or above for patients 15 to
49 or .70 years old may be considered to
decrease mortality and improve outcomes
CPP thresholds
 Level IIB
 The recommended target CPP value for
survival and favourable outcomes is between
60 and 70 mm Hg.
 Whether 60 or 70 mm Hg is the minimum
optimal CPP threshold is unclear and may
depend upon the autoregulatory status of the
patient.
 CPP thresholds

 Level III
 Avoiding aggressive attempts to maintain
CPP .70 mm Hg with fluids and pressors may
be considered because of the risk of adult
respiratory failure.
 Cerebral Blood Vessel

Vasodilation Vasoconstriction
Cerebral Blood Flow

Intracranial pressure

50 100 mm Hg

Cerebral Perfusion Pressure

Cerebral blood flow

B Cerebral perfusion pressure

Cerebral blood flow

C
Cerebral perfusion pressure
 Cerebral blood vessels

Passive vasodilation(“vaso-motor paralysis”)

Cerebral blood flow

Intracranial pressure

Cerebral perfusion pressure

D
Optimal CPP

Crit Care Med 2010 Vol. 38, No. 5

 r = 0.79, p = 0.000001
CPPPbrO2 [mmHg]

CPPOPT [mmHg]

Relationship between the cerebrovascular pressure reactivity-based optimal

level of cerebral perfusion pressure (CPPOPT) and the CPP at the partial
pressure of brain tissue oxygen (PbrO2) change point (CPPPbrO2) from 30
patients.
 30
25
20
PaO2 (mmHg)

15
10
PRx
PRx

5 PbrO2
0
50- 60- 70- 80- 90- 100
55 65 75 85 95 -
105

CPP (mmHg)

Illustrative individual relationship between CPP, index of cerebrovascular pressure

reactivity (PRx) (black line), and PbrO2 (gray line) in a patient with a relatively low
optimal level of CPP at 60 to 65 mm Hg. PbrO2 change point is at 55 to 60 mm Hg.
 30

25

20

15
PaO2 (mmHg)

10 PRx
PRx

PbrO2
5

0
30- 40- 50- 60- 70-75 80-
35 45 55 65 85

CPP (mmHg)

Illustrative individual relationship between CPP, index of cerebrovascular

pressure reactivity (PRx) (black line), and PbrO2(gray line) in a patient with a
relatively high optimal level of CPP at 90 to 95 mm Hg. PbrO2 change point is
at 95 to 100 mm Hg.
Johnston AJ, Steiner LA, Chatfield DA et al Intensive Care Med (2004) 30:791–797
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