The lower limit of reactivity as a potential individualised cerebral perfusion pressure target in traumatic brain injury: a CENTER-TBI high-resolution sub-study analysis

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Background
A previous retrospective single-centre study suggested that the percentage of time spent with cerebral perfusion pressure (CPP) below the individual lower limit of reactivity (LLR) is associated with mortality in traumatic brain injury (TBI) patients. We aim to validate this in a large multicentre cohort.

Methods
Recordings from 171 TBI patients from the high-resolution cohort of the CENTER-TBI study were processed with ICM+ software. We derived LLR as a time trend of CPP at a level for which the pressure reactivity index (PRx) indicates impaired cerebrovascular reactivity with low CPP. The relationship with mortality was assessed with Mann-U test (first 7-day period), Kruskal–Wallis (daily analysis for 7 days), univariate and multivariate logistic regression models. AUCs (CI 95%) were calculated and compared using DeLong’s test.

Results
Average LLR over the first 7 days was above 60 mmHg in 48% of patients. %time with CPP < LLR could predict mortality (AUC 0.73, p =  < 0.001). This association becomes significant starting from the third day post injury. The relationship was maintained when correcting for IMPACT covariates or for high ICP.

Conclusions
Using a multicentre cohort, we confirmed that CPP below LLR was associated with mortality during the first seven days post injury.
OriginalsprogEngelsk
Artikelnummer194
TidsskriftCritical Care
Vol/bind27
Udgave nummer1
Antal sider14
ISSN1364-8535
DOI
StatusUdgivet - 2023

Bibliografisk note

Funding Information:
The authors would like to thank Abhishek Dixit for his contribution to the core CENTER-TBI database using Opal software and his guidance for data retrieval and interpretation. Audny Anke (Department of Physical Medicine and Rehabilitation, University hospital Northern Norway), Ronny Beer (Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria), Bo Michael Bellander (Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden), Erta Beqiri (NeuroIntensive Care, Niguarda Hospital, Milan, Italy), Andras Buki (Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary; Neurotrauma Research Group, János Szentágothai Research Centre, University of Pécs, Pécs, Hungary), Manuel Cabeleira (Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK), Marco Carbonara (Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy), Arturo Chieregato (NeuroIntensive Care, Niguarda Hospital, Milan, Italy), Giuseppe Citerio (NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy; School of Medicine and Surgery, Università Milano Bicocca, Milano, Italy), Hans Clusmann (Department of Neurosurgery, Medical Faculty RWTH Aachen University, Aachen, Germany), Endre Czeiter (Department of Neurosurgery, University of Pecs, Pecs, Hungary; MTA-PTE Clinical Neuroscience MR Research Group and Janos Szentagothai Research Centre, University of Pecs, Hungarian Brain Research Program (Grant No. KTIA 13 NAP-A-II/8), Pecs, Hungary), Marek Czosnyka (Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK), Bart Depreitere (Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium), Ari Ercole (Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK), Shirin Frisvold (Department of Anesthesiology and Intensive care, University Hospital Northern Norway, Tromso, Norway), Raimund Helbok (Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria), Stefan Jankowski (Neurointensive Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK), Daniel Kondziella (Departments of Neurology, Clinical Neurophysiology and Neuroanesthesiology, Region Hovedstaden Rigshospitalet, Copenhagen, Denmark), Lars-Owe Koskinen (Department of Clinical Neuroscience, Neurosurgery, Umeå University, Umeå, Sweden), Ana Kowark (Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany), David K. Menon (Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK), Geert Meyfroidt (Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium), Kirsten Moeller (Department Neuroanesthesiology, Region Hovedstaden Rigshospitalet, Copenhagen, Denmark), David Nelson (Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden), Anna Piippo-Karjalainen (Helsinki University Central Hospital, Helsinki, Finland), Andreea Radoi (Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain), Arminas Ragauskas (Department of Neurosurgery, Kaunas University of technology and Vilnius University, Vilnius, Lithuania), Rahul Raj (Helsinki University Central Hospital, Helsinki, Finland), Jonathan Rhodes (Department of Anaesthesia, Critical Care & Pain Medicine NHS Lothian & University of Edinburg, Edinburgh, UK), Saulius Rocka (Department of Neurosurgery, Kaunas University of technology and Vilnius University, Vilnius, Lithuania), Rolf Rossaint (Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany), Juan Sahuquillo (Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain), Oliver Sakowitz (Klinik für Neurochirurgie, Klinikum Ludwigsburg, Ludwigsburg, Germany; Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany), Peter Smielewski (Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK), Nino Stocchetti (Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy), Nina Sundström (Department of Radiation Sciences, Biomedical Engineering, Umea University, Umea, Sweden), Riikka Takala (Perioperative Services, Intensive Care Medicine, and Pain Management , Turku University Central Hospital and University of Turku, Turku, Finland), Tomas Tamosuitis (Neuro-intensive Care Unit, Kaunas University of Health Sciences, Kaunas, Lithuania), Olli Tenovuo (Rehabilitation and Brain Trauma, Turku University Central Hospital and University of Turku, Turku, Finland), Andreas Unterberg (Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany), Peter Vajkoczy (Neurologie, Neurochirurgie und Psychiatrie, Charité – Universitätsmedizin Berlin, Berlin, Germany), Alessia Vargiolu (NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy), Rimantas Vilcinis (Department of Neurosurgery, Kaunas University of Health Sciences, Kaunas, Lithuania), Stefan Wolf (Department of Neurosurgery, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany), Alexander Younsi (Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany), Frederick A. Zeiler (Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK; Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada)

Funding Information:
Data used in preparation of this manuscript were obtained in the context of CENTER-TBI, a large collaborative project with the support of the European Union 7th Framework program (EC Grant 602150). Additional funding was obtained from the Hannelore Kohl Stiftung (Germany), from OneMind (USA) and from Integra LifeSciences Corporation (USA). For the writing of this manuscript Erta Beqiri was supported by CTBI scholarship (EC Grant n°:602150) and is currently supported by the Medical Research Council (Grant no.: MR N013433-1) and by the Gates Cambridge Scholarship. FAZ receives research support from the Natural Sciences and Engineering Research Council of Canada (NSERC)(DGECR-2022–00260, RGPIN-2022–03621 and ALLRP-576386–22), Canadian Institutes of Health Research (CIHR), the MPI Neuroscience Research Operating Fund, the Health Sciences Centre Foundation Winnipeg, the Canada Foundation for Innovation (CFI) (Project #: 38583), Research Manitoba (Grant #: 3906), and the University of Manitoba MPI Professorship in Neuroscience. MJH Aries and J Tas are supported by a grant from the ‘Brain Battle’ Foundation (HersenStrijd fonds) from the University Maastricht, The Netherlands. Joseph Donnelly is supported by the Neurological Foundation of New Zealand. M. M. Placek was supported by the European Union seventh Framework Program (Grant 602150) for Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) until March 2021 and by Action Medical Research (Grant GN2609) for Studying Trends of Auto-Regulation in Severe Head Injury in Paediatrics (STARSHIP) until December 2021. Marek Czosnyka is supported by National Institute for Health Research (NIHR), Cambridge Biomedical Research Centre.

Publisher Copyright:
© 2023, The Author(s).

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