Assessment of Optimal Arterial Pressure with Near-Infrared Spectroscopy in Traumatic Brain Injury Patients.

Abstract

In patients with severe traumatic brain injury (TBI), simultaneous measurement of intracranial and arterial blood pressure (ICP and ABP, respectively) allows monitoring of cerebral perfusion pressure (CPP) and the assessment of cerebral autoregulation (CA). CPP, a difference between ICP and ABP, is the pressure gradient that drives oxygen delivery to cerebral tissue. CA is the ability of cerebral vasculature to maintain stable blood flow despite changes in CPP and thus, is an important homeostatic mechanism. Pressure reactivity index (PRx), a moving Pearson's correlation between slow waves in ICP and ABP, has been most frequently cited in literature over the past two decades as a tool for CA evaluation. However, in some clinical situations, ICP monitoring may be unavailable or contraindicated. In such cases, simultaneous mean arterial pressure (MAP) monitoring and near-infrared spectroscopy (NIRS) can be used for CA assessment by cerebral oximetry index (COx), allowing calculation of the optimal blood pressure (MAPOPT). The purpose of this study was to compare regional oxygen saturation (rSO2)-based CA (COx) with ICP/ABP-based CA (PRx) in TBI patients and to compare MAPOPT derived from both technologies. Three TBI patients were monitored at the bedside to measure CA using both PRx and COx. Patients were monitored daily for up to 3days from TBI. Averaged PRx and COx-, and PRx and COx-based MAPOPT were compared using Pearson's correlation. Bias analysis was performed between these same CA metrics. Correlation between averaged values of COx and PRx was R=0.35, p=0.15. Correlation between optimal MAP calculated for COx and PRx was R=0.49, p<0.038. Bland-Altman analysis showed moderate agreement with a bias of 0.16±0.23 for COx versus PRx and good agreement with a bias of 0.39±7.89 for optimal MAP determined by COx versus PRx. Non-invasive measurement of CA by NIRS (COx) is not correlated with invasive ICP/ABP-based CA (PRx). However, the determination of MAPOPT using COx is correlated with MAPOPT derived from PRx. Obtained results demonstrate that COx is not an acceptable substitute for PRx in TBI patients. However, in some TBI cases, NIRS may be useful in determining MAP determination.