Cerebral blood flow and metabolism in severe brain injury: the role of pressure autoregulation during cerebral perfusion

pressure management

Reference: 1. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg 83: 949-962, 1995 2. Cerebral blood flow and metabolism in severe brain injury: the role of pressure autoregulation during cerebral perfusion pressure mangement. Intensive care medicine 26: 202-205, 2000

Ri / VS May 6, 2002

Introduction

Cerebral autoregulation
SABP CPP Spontaneous Ischemic Response Vascular volume Pharmacologic Mechanical Metabolism

Edema CSF Withdrawal

ICP

Vasoconstriction

CMR-O2 Viscosity O2 delivery Hypocapnia Pharmacologic

CBV

CPP management (Rosner et al. 1995) 1. Monitoring: CVP, MAP, ICP 2. Ventilation: continuous hyperventilation was not used as a therapeutic modality. 3. Fluid management: euvolemia to moderate hypervolemia. Use of albumin and PRBC 4. Keep CPP > 70 mmHg 5. Administration of vasopressors 6. Mannitol

THE QUESTION IS ?

The risk of hyperemia Impaired autoregulation

Objective

To ascertain if norepinephrine can be used as part of CPP management to increase MAP without causing cerebral hyperemia To assess pressure autoregulation in severe HI patients

Methods

12 severe HI patients; median GCS was 6 CPP management protocol; keep CPP > 70 mmHg Pressure autoregulation test: norepinephrine raised MAP by 30%. Define intact if %CPP/%CVR2 (CVR= CPPCBF) 133 Regional CBF was obtained using Xe inhalation Transcranial Doppler (TCD) of the MCA SjO2 76%: hyperemia; SjO250%: increased cerebral extraction of oxygen

Results

Autoregulation was found to be intact in 10 patients and defective in 2. Norepinephrine infusion increased MAP by 26% and reduced ICP by 15%, leading to an increase in CPP of 33% Preserved autoregulation: CBF Impaired autoregulation: CBF

Discussion(I)

Norepinephrine can be used to increase BP without potentiating cerebral hyperemia only if pressure autoregulation is preserved A direct dependency of the ICP from MAP was noted and systemic hypertension may be harmful because autoregulation is impaired

Discussion (II)

SjO2 and TCD: good indicator of the adequacy of perfusion and hyperemia ? Ways of assessment of pressure autoregulation The importance of orienting therapy according to the pressure autoregulation status of the cerebral circulation

Thanks for your attention !