Tag Archives: monitoring

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ICP Monitoring: Less Is More?

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Management of severe traumatic brain injury (TBI) routinely involves monitoring and control of cerebral perfusion pressure. Monitoring is typically accomplished with an invasive monitor, with the extraventricular drain (EVD) and fiberoptic intraparenchymal monitors (IP) being the most common.

The extraventricular drain is preferred in many centers because it not only monitors pressures, but it can also be used to drain cerebrospinal fluid (CSF) to actively try to decrease intracranial pressure (ICP). But could less really be more? Surgeons at Massachusetts General reviewed 229 patients with one of these monitors, looking at outcomes and complications. They found the following interesting results:

  • There was no difference in mortality between the two monitor types
  • The EVD patients did not require surgical decompression as often, possibly because of the ability to decrease ICP through drainage
  • The EVD patients were monitored longer, and had a longer ICU length of stay. This was also associated with a longer hospital length of stay.
  • Complications were much more common in the extraventricular drain group (31%). The most common complications were no drainage / thrombosis (15%) and malposition (10%). Hemorrhage only occurred in 1.6% of patients. 
  • Fiberoptic monitors had a lower complication rate (8%). The most common was malfunction leading to loss of monitoring (12%). Hemorrhage only occurred in 0.6% of patients.

Bottom line: Don’t change your monitoring technique yet. Much more work needs to be done to flesh out this small retrospective study. But it should prompt us to take a critical look for better indications and contraindications for each type of monitor.

Reference: Intraparenchymal versus extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more?J Am Coll Surg 214(6):950-957, 2012.

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Technology: Real Time Cerebral Blood Flow Monitoring For TBI

Here’s a new toy that has recently received some funding from the US military. It allows real-time monitoring of cerebral blood flow. It may help identify flow problems from elevated intracranial pressure (ICP) or vasospasm early on, allowing prompt initiation of appropriate therapies to increase blood flow.

This device uses an array of ultrasound beams and locks onto the middle cerebral artery. It then continuously monitors blood flow and displays the result in real time. I predict that there will be a learning curve with this one, similar to near infrared monitoring of tissue perfusion. What’s a normal baseline? What kind of variation is considered “normal?” We’ll have to answer these questions before this tool is ready for prime time. Ultimately, it may allow noninvasive monitoring of ICP in the intensive care unit.

Credit: Physiosonics, Bellevue, WA.

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AAST 2011: Placement of ICP Monitors By Non-Neurosurgeons

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Traumatic brain injury (TBI) is a common injury world-wide, but neurosurgeons are scarce. Traditionally, neurosurgeons are the ones to place invasive monitors to watch intracranial pressure (ICP). But what about injured people who are taken to a hospital where there is no available neurosurgeon?

A group at Wichita, Kansas looked at their 10 year experience with ICP monitor placement, where it can be done by neurosurgeons, trauma surgeons or general surgical residents (under trauma surgeon supervision). A total of 63 were placed by neurosurgeons, 30 by trauma surgeons, and 464 by residents under supervision. The usual demographics, including hospital stay, were the same across groups. There were essentially no significant differences based on who placed the monitor. The abstract did not state whether the monitors were extradural or intraventricular, or both.

There were only three iatrogenic bleeds, and all occurred with resident placed monitors. None were clinically significant. Malfunction rate was about 5% across all groups. Monitors had to be replaced at some point in about 11% of all three groups. One CNS infection occurred in a patient with a resident-placed monitor.

Bottom line: With proper training and supervision, ICP monitors can be placed by just about anyone. This is particularly important in more rural locations where there are few if any neurosurgeons. But as always, this process needs to be monitored carefully by the hospital’s Trauma Performance Improvement / Patient Safety program (PIPS).

Related posts:

Reference: Placement of intracranial pressure monitors by non-neurosurgeons: good outcomes are achieved. AAST 2011 Annual Meeting, Paper 72.

General

ICP Monitoring: Less Is More?

Leave a comment

Management of severe traumatic brain injury (TBI) routinely involves monitoring and control of cerebral perfusion pressure. Monitoring is typically accomplished with an invasive monitor, with the extraventricular drain (EVD) and fiberoptic intraparenchymal monitors (IP) being the most common.

The extraventricular drain is preferred in many centers because it not only monitors pressures, but it can also be used to drain cerebrospinal fluid (CSF) to actively try to decrease intracranial pressure (ICP). But could less really be more? Surgeons at Massachusetts General reviewed 229 patients with one of these monitors, looking at outcomes and complications. They found the following interesting results:

  • There was no difference in mortality between the two monitor types
  • The EVD patients did not require surgical decompression as often, possibly because of the ability to decrease ICP through drainage
  • The EVD patients were monitored longer, and had a longer ICU length of stay. This was also associated with a longer hospital length of stay.
  • Complications were much more common in the extraventricular drain group (31%). The most common complications were no drainage / thrombosis (15%) and malposition (10%). Hemorrhage only occurred in 1.6% of patients. 
  • Fiberoptic monitors had a lower complication rate (8%). The most common was malfunction leading to loss of monitoring (12%). Hemorrhage only occurred in 0.6% of patients.

Bottom line: Don’t change your monitoring technique yet. Much more work needs to be done to flesh out this small retrospective study. But it should prompt us to take a critical look for better indications and contraindications for each type of monitor.

Reference: Intraparenchymal versus extracranial ventricular drain intracranial pressure monitors in traumatic brain injury: less is more? Presented at the 34th Annual Residents Trauma Papers Competition at the American College of Surgeons 89th Annual Meeting, March 10, 2011, Washington DC.