Top

Published in:

Open Access 01-09-2021 | Central Nervous System Trauma | Original

Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study

Authors: Giuseppe Citerio, Chiara Robba, Paola Rebora, Matteo Petrosino, Eleonora Rossi, Letterio Malgeri, Nino Stocchetti, Stefania Galimberti, David K. Menon, on behalf of the Center-TBI participants and investigators

Published in: Intensive Care Medicine | Issue 9/2021

Abstract

Purpose

To describe the management of arterial partial pressure of carbon dioxide (PaCO₂) in severe traumatic brain-injured (TBI) patients, and the optimal target of PaCO₂ in patients with high intracranial pressure (ICP).

Methods

Secondary analysis of CENTER-TBI, a multicentre, prospective, observational, cohort study. The primary aim was to describe current practice in PaCO₂ management during the first week of intensive care unit (ICU) after TBI, focusing on the lowest PaCO₂ values. We also assessed PaCO₂ management in patients with and without ICP monitoring (ICP_m), and with and without intracranial hypertension. We evaluated the effect of profound hyperventilation (defined as PaCO₂ < 30 mmHg) on long-term outcome.

Results

We included 1100 patients, with a total of 11,791 measurements of PaCO₂ (5931 lowest and 5860 highest daily values). The mean (± SD) PaCO₂ was 38.9 (± 5.2) mmHg, and the mean minimum PaCO₂ was 35.2 (± 5.3) mmHg. Mean daily minimum PaCO₂ values were significantly lower in the ICP_m group (34.5 vs 36.7 mmHg, p < 0.001). Daily PaCO₂ nadir was lower in patients with intracranial hypertension (33.8 vs 35.7 mmHg, p < 0.001). Considerable heterogeneity was observed between centers. Management in a centre using profound hyperventilation (HV) more frequently was not associated with increased 6 months mortality (OR = 1.06, 95% CI = 0.77–1.45, p value = 0.7166), or unfavourable neurological outcome (OR 1.12, 95% CI = 0.90–1.38, p value = 0.3138).

Conclusions

Ventilation is manipulated differently among centers and in response to intracranial dynamics. PaCO₂ tends to be lower in patients with ICP monitoring, especially if ICP is increased. Being in a centre which more frequently uses profound hyperventilation does not affect patient outcomes.

Available only for authorised users

Hoiland RL, Fisher JA, Ainslie PN (2019) Regulation of the Cerebral Circulation by Arterial Carbon Dioxide. In: Compr. Physiol. Wiley. https://doi.org/10.1002/cphy.c180021

Gouvea Bogossian E, Peluso L, Creteur J, Taccone FS (2021) Hyperventilation in Adult TBI Patients: How to Approach It? Neurol Front. https://doi.org/10.3389/fneur.2020.580859CrossRef

Lundberg N, Kjallquist A, Bien C (1949) Reduction of increased intracranial pressure by hyperventilation. A therapeutic aid in neurological surgery, Acta Psychiatr. Scand. Suppl. 34:1–64. http://www.ncbi.nlm.nih.gov/pubmed/14418913.

Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F (2017) Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol. https://doi.org/10.3389/fneur.2017.00250CrossRefPubMedPubMedCentral

Stocchetti N, Maas AIR, Chieregato A, van der Plas AA (2005) Hyperventilation in Head Injury. Chest 127:1812–1827. https://doi.org/10.1378/chest.127.5.1812CrossRefPubMed

Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK (2017) Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol 16:452–464. https://doi.org/10.1016/S1474-4422(17)30118-7CrossRef

Coles JP, Minhas PS, Fryer TD, Smielewski P, Aigbirihio F, Donovan T, Downey SPMJ, Williams G, Chatfield D, Matthews JC, Gupta AK, Carpenter TA, Clark JC, Pickard JD, Menon DK (2002) Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates*. Crit Care Med 30:1950–1959. https://doi.org/10.1097/00003246-200209000-00002CrossRefPubMed

Curley G, Kavanagh BP, Laffey JG (2010) Hypocapnia and the injured brain: More harm than benefit. Crit Care Med 38:1348–1359. https://doi.org/10.1097/CCM.0b013e3181d8cf2bCrossRefPubMed

Cnossen MC, Huijben JA, van der Jagt M, Volovici V, van Essen T, Polinder S, Nelson D, Ercole A, Stocchetti N, Citerio G, Peul WC, Maas AIR, Menon D, Steyerberg EW, Lingsma HF (2017) Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. Crit Care 21:233. https://doi.org/10.1186/s13054-017-1816-9CrossRefPubMedPubMedCentral

10.

N Carney, AM Totten, C OReilly, JS Ullman, GWJ Hawryluk, MJ Bell, SL Bratton, R Chesnut, OA Harris, N Kissoon, AM Rubiano, L Shutter, RC Tasker, MS Vavilala, J Wilberger, DW Wright, J Ghajar (2017) Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. https://doi.org/10.1227/NEU.0000000000001432.

11.

Roberts I, Schierhout G (1997) Hyperventilation therapy for acute traumatic brain injury. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD000566CrossRefPubMedCentral

12.

Robba C, Poole D, McNett M, Asehnoune K, Bösel J, Bruder N, Chieregato A, Cinotti R, Duranteau J, Einav S, Ercole A, Ferguson N, Guerin C, Siempos II, Kurtz P, Juffermans NP, Mancebo J, Mascia L, McCredie V, Nin N, Oddo M, Pelosi P, Rabinstein AA, Neto AS, Seder DB, Skrifvars MB, Suarez JI, Taccone FS, van der Jagt M, Citerio G, Stevens RD (2020) Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus. Intensive Care Med. https://doi.org/10.1007/s00134-020-06283-0CrossRefPubMedPubMedCentral

13.

Hawryluk GWJ, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin R, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo D, Patel M, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein D, Stocchetti N, Taccone FS, Timmons S, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Chesnut RM (2019) A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. https://doi.org/10.1007/s00134-019-05805-9CrossRefPubMedPubMedCentral

14.

Maas AIR, Menon DK, Steyerberg EW, Citerio G, Lecky F, Manley GT, Hill S, Legrand V, Sorgner A (2015) Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI). Neurosurgery. https://doi.org/10.1227/NEU.0000000000000575CrossRefPubMed

15.

Steyerberg EW, Wiegers E, Sewalt C, et al (2019) Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study. Lancet Neurol. https://doi.org/10.1016/S1474-4422(19)30232-7CrossRefPubMed

16.

Huijben JA, Wiegers EJA, Lingsma HF, Citerio G, Maas AIR, Menon DK, Ercole A, Nelson D, van der Jagt M, Steyerberg EW, Helbok R, Lecky F, Peul W, Birg T, Zoerle T, Carbonara M, Stocchetti N (2020) Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis. Intensive Care Med 46:995–1004. https://doi.org/10.1007/s00134-020-05965-zCrossRefPubMedPubMedCentral

17.

Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A (2021) Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 25:78. https://doi.org/10.1186/s13054-020-03370-yCrossRefPubMedPubMedCentral

18.

Wilson JTL, Pettigrew LEL, Teasdale GM (1998) Structured Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for Their Use. J Neurotrauma. https://doi.org/10.1089/neu.1998.15.573CrossRefPubMed

19.

Maas AIR, Marmarou A, Murray GD, Teasdale SGM, Steyerberg EW (2007) Prognosis and Clinical Trial Design in Traumatic Brain Injury: The IMPACT Study. J Neurotrauma 24:232–238. https://doi.org/10.1089/neu.2006.0024CrossRefPubMed

20.

Cnossen M, van Essen TA, Ceyisakar IE, Polinder S, Andriessen T, van der Naalt J, Haitsma I, Horn J, Franschman G, Vos P, Peul W, Menon DK, Maas A, Steyerberg E, Lingsma H (2018) Adjusting for confounding by indication in observational studies: a case study in traumatic brain injury. Clin Epidemiol 10:841–852. https://doi.org/10.2147/CLEP.S154500CrossRefPubMedPubMedCentral

21.

Vik A, Nag T, Fredriksli OA, Skandsen T, Moen KG, Schirmer-Mikalsen K, Manley GT (2008) Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 109:678–684. https://doi.org/10.3171/JNS/2008/109/10/0678CrossRefPubMed

22.

Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF (1991) Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg. https://doi.org/10.3171/jns.1991.75.5.0731CrossRefPubMed

23.

Coles JP, Fryer TD, Coleman MR, Smielewski P, Gupta AK, Minhas PS, Aigbirhio F, Chatfield DA, Williams GB, Boniface S, Carpenter TA, Clark JC, Pickard JD, Menon DK (2007) Hyperventilation following head injury: Effect on ischemic burden and cerebral oxidative metabolism*. Crit Care Med. https://doi.org/10.1097/01.CCM.0000254066.37187.88CrossRefPubMed

24.

Brandi G, Stocchetti N, Pagnamenta A, Stretti F, Steiger P, Klinzing S (2019) Cerebral metabolism is not affected by moderate hyperventilation in patients with traumatic brain injury. Crit Care. https://doi.org/10.1186/s13054-018-2304-6CrossRefPubMedPubMedCentral

25.

Diringer MN, Videen TO, Yundt K, Zazulia AR, Aiyagari V, Dacey RG, Grubb RL, Powers WJ (2002) Regional cerebrovascular and metabolic effects of hyperventilation after severe traumatic brain injury. J Neurosurg 96:103–108. https://doi.org/10.3171/jns.2002.96.1.0103CrossRefPubMed

26.

Diringer MN, Yundt K, Videen TO, Adams RE, Zazulia AR, Deibert E, Aiyagari V, Dacey RG, Grubb RL, Powers WJ (2000) No reduction in cerebral metabolism as a result of early moderate hyperventilation following severe traumatic brain injury. J Neurosurg 92:7–13. https://doi.org/10.3171/jns.2000.92.1.0007CrossRefPubMed

27.

Neumann J-O, Chambers IR, Citerio G, Enblad P, Gregson BA, Howells T, Mattern J, Nilsson P, Piper I, Ragauskas A, Sahuquillo J, Yau YH, Kiening K (2008) The use of hyperventilation therapy after traumatic brain injury in Europe: an analysis of the brain database. Intensive Care Med 34:1676. https://doi.org/10.1007/s00134-008-1123-7CrossRefPubMed

28.

Gordon E (1971) Controlled respiration in the management of patients with traumatic brain injuries. Acta Anaesthesiol Scand. https://doi.org/10.1111/j.1399-6576.1971.tb05461.xCrossRefPubMed

Title: Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study
Authors: Giuseppe Citerio
Chiara Robba
Paola Rebora
Matteo Petrosino
Eleonora Rossi
Letterio Malgeri
Nino Stocchetti
Stefania Galimberti
David K. Menon
on behalf of the Center-TBI participants and investigators
Publication date: 01-09-2021
Publisher: Springer Berlin Heidelberg
Keywords: Central Nervous System Trauma
Intracranial Hypertension
Published in: Intensive Care Medicine / Issue 9/2021
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-021-06470-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Management of arterial partial pressure of carbon dioxide in the first week after traumatic brain injury: results from the CENTER-TBI study

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 9/2021

Critical care after the COVID-19 outbreak in China: lessons and renaissance

Secondary sclerosing cholangitis: an emerging complication in critically ill COVID-19 patients

The gut in COVID-19

Differential effects of prone position in COVID-19-related ARDS in low and high recruiters

The relationship between adrenocortical candidate gene expression and clinical response to hydrocortisone in patients with septic shock

Why and how do we need comprehensive international clinical epidemiology of ARDS?