Multimodal monitoring in patients with head injury: Evaluation of the effects of treatment on cerebral oxygenation

Background: Recently, invasive intensive care unit monitoring of cerebral oxygenation has become feasible. The purpose of this study was to investigate the effects of standard therapeutic interventions used in the treatment of intracranial hypertension on cerebral oxygenation and other physiologic parameters in comatose patients. Methods: In the neurosurgical intensive care unit, Ptio(2), and jugular bulb oxygen saturation (Sjvo(2)), arterial blood pressure, intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were prospectively studied (0.1 Hz acquisition rate) with a multimodal monitoring system in 21 patients with severe traumatic brain injury during various treatment modalities: dopamine and mannitol infusion, head positioning, and induced arterial hypocapnia. Results: For baseline CPP values below 40 mm Hg, dopamine infusion was more effective in decreasing ICP and improving Ptio(2) and Sjvo(2) than for initial CPP values above 60 mm Hg. Treatment with mannitol, although improving CPP and lowering ICP, did not affect Ptio(2) and Sjvo(2). CPP in this group, however, was always above 60 mm Hg. Forced hyperventilation to an end-tidal Pco(2) of 21 mm Hg normalized ICP and CPP, but significantly reduced cerebral oxygenation. Conclusion: 4 CPP > 60 mm Hg emerges as the crucial factor guaranteeing sufficient brain oxygenation. Any intervention used to further elevate CPP does not improve cerebral oxygenation, to the contrary, forced hyperventilation even bears the risk of inducing brain ischemia.