![Page 1: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/1.jpg)
CLINICAL DECISIONS BASED ON MICRODIALYSIS DATA IN SEVERE HEAD INJURY
P.G. Papanikolaou, E.Papadopoulos, A.Markellos, K.Barkas, S.Stamatiou, A.Venetikidis, N.Papageorgiou, M.Fratzoglou, E.Chatzidakis, T.Kyriakou, T.S. Paleologos, K.Kazdaglis
Neurosurgical Department,General Hospital of Nikea - Piraeus, Athens, Greece
![Page 2: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/2.jpg)
NOTHING TO DISCLOSE
![Page 3: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/3.jpg)
Οur experience
Multimodal neuromonitoring in TBI patients using intraparenchymal brain catheters
Twist hand drill burr hole Single same burr hole 5.3 mm 3 – lumen cranial bolt (LICOX) ICP, PtiO2, microdialysis
![Page 4: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/4.jpg)
Treatment strategies
CPP targeted therapy
- CPP > 60 mm Hg - ICP < 20 mm Hg - PtiO2 > 20 mm Hg
- L / P ≤ 25
![Page 5: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/5.jpg)
Catheter’s tip
![Page 6: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/6.jpg)
What about microdialysis?
Microdialysis only for research
•Not officially recommended as a clinical tool in TBI
![Page 7: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/7.jpg)
Some centers favour it
and not only in
Hillered L, Vespa PM, Hovda DA. Translational neurochemical research in acute human brain injury: the current status and potential future for cerebral microdialysis. J Neurotrauma. 2005 Jan;22(1):3-41.
![Page 8: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/8.jpg)
Our center’s opinion
Clinical decisions based on microdialysis data -Lactate to Pyruvate concetrations’ ratio (L/P) - in severe head injury: Treatment protocol of patients with peaks of
intracranial hypertension up to 30 mmHg (“group A”)
Evaluation of success and duration of thiopenthal administration (“group B”)
Decision for evacuation or not of “border-line” sized hematomas (“group C”)
![Page 9: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/9.jpg)
GROUP A max ICP mean L/P age sex GOS
Pt 1 33 32,7 59 f 5
Pt 2 35 31 43 m 5
Pt 3 35 24 22 f 4
Pt 4 28 20 27 m 5
Pt 5 31 31 29 m 5
Pt 6 29 23,1 41 m 4
GROUP B
Pt 1 40 32 28 m 5
Pt 2 117 28,4 17 m 1
Pt 3 122 42,7 41 m 1
Pt 4 37 31,1 35 m 5
Pt 5 121 46,7 28 m 1
Pt 6 98 41,2 39 m 5
GROUP C
Pt 1 27 30,7 32 m 1
Pt 2 34 24,6 21 m 4
Pt 3 14 23,8 23 m 5
Pt 4 27 28,7 22 m 5
Pt 5 40 32 28 m 5
Pt 6 33 32,7 59 f 5
![Page 10: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/10.jpg)
![Page 11: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/11.jpg)
Group A
6 patients episodes of intracranial hypertension
up to 30mmHg without significant change of the L/P
ratio Decision to treat with mannitol only
or to proceed to second tier therapy with barbiturates
![Page 12: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/12.jpg)
Group A : Sporadic ICP elevations up to 30mmHg – just sedation and mannitol or something more aggressive ?
![Page 13: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/13.jpg)
Group B
6 patients refractory intracranial hypertension treated by barbiturates L/P ratio was the main criteria for
evaluation and duration of the treatment
![Page 14: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/14.jpg)
Group B : Conservative treatment. Barbiturate therapy for refractory intracranial hypertension. Evaluation of continuation of barbiturate induced coma
![Page 15: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/15.jpg)
Normalization of L/P before ICP
![Page 16: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/16.jpg)
Discharge CT scan
GOS 5 at 6 months
![Page 17: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/17.jpg)
Group C
6 patients intracranial hematoma initially
treated conservatively L/P ratio in association with ICP
determined the decision for a surgical evacuation
![Page 18: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/18.jpg)
Group C : 59 yrs, female Evacuation or not?
![Page 19: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/19.jpg)
Based on values of L/P<25 : conservative treatment
![Page 20: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/20.jpg)
CT scan at two months (discharge)
GOS 4 at 6 months
![Page 21: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/21.jpg)
GOS
Good
Moderate
Bad
Group AGroup BGroup C
![Page 22: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/22.jpg)
Handicaps
Difficulty of insertion of the catheter via the 3/lumen bolt
Measurement frequency ICU personnel deficiency done by N/S residents
Lack of automatic data registration National health system structure :
patients → ICU somewhere else Hospital and social insurance managers
not so helpful
![Page 23: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/23.jpg)
Conclusions
Multimodal neuromonitoring using brain catheters seems to be safe, reliable and useful tool
Data provided by microdialysis seems to be helpful taking appropriate clinical decisions
Especially useful in barbiturate therapy
![Page 24: Using microdialysis for clinical decisions in head injury](https://reader034.vdocuments.us/reader034/viewer/2022042515/555ee370d8b42ab6408b51e1/html5/thumbnails/24.jpg)
References1.Poca MA et al. Percutaneous implantation of cerebral microdialysis catheters by twist-drill
craniostomy in neurocritical patients: description of the technique and results of a feasibility study in 97 patients. J Neurotrauma. 2006 Oct;23(10):1510-7.
2. Tisdall MM et al Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006 Jul;97(1):18-25. Epub 2006 May 12
3. Hutchinson PJ. Microdialysis in traumatic brain injury--methodology and pathophysiology. Acta Neurochir Suppl. 2005;95:441-5
4. Martins RS et al. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. 2003 Aug;60(2):98-104
5. Sarrafzadeh AS et al. Detection of secondary insults by brain tissue pO2 and bedside microdialysis in severe head injury. Acta Neurochir Suppl. 2002;81:319-21.
6. Stahl N et al. Intracerebral microdialysis and bedside biochemical analysis in patients with fatal traumatic brain lesions. Acta Anaesthesiol Scand. 2001 Sep;45(8):977-85.
7. Hecimovic I et al. Intracranial infection after missile brain wound: 15 war cases. Zentralbl Neurochir. 2000;61(2):95-102.
8. Goodman JC et al. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients. J Neurotrauma. 1996 Oct;13(10):549-56.
9. Brain Trauma Foundation Guidelines 2007. J Neurotrauma 2007;24 Suppl 1:S91-5
10. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flow Monitoring. Intensive Care Med (2007) 33:1263–1271
11. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. II. Cerebral oxygenation monitoring and microdialysis. Intensive Care Med (2007) 33:1322–1328