Neurocritical care
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Prognostication is fundamental to determining the intensity of care offered for many critically ill patients with severe acute brain injury (SABI). Inherent uncertainties linked to predicting outcomes for patients with SABI primarily arise from a lack of complete data regarding the natural disease/injury progression that follows various forms of SABI, stemming from early withdrawal of life-sustaining treatment. This potential bias has led to limitations in using outcome data associated with clinical grading scales and a risk of perpetuating high mortality following SABI, leading to self-fulfilling prophecies. The aims of this article are to (1) review contemporary prognostication practices among clinicians for patients with SABI, (2) discuss inherent challenges in prognosticating outcomes following SABI, (3) summarize statements and guidelines from professional societies regarding SABI prognostication, and (4) identify directions for future research in prognostication after SABI.
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The 'CPPopt-Guided Therapy: Assessment of Target Effectiveness' (COGiTATE) randomised controlled trial demonstrated the feasibility and safety of targeting an automated cerebral perfusion pressure (CPP) tailored to optimize cerebrovascular autoregulation (CPPopt) in patients with traumatic brain injury (TBI) requiring intracranial pressure management. The average values of the autoregulation index known as the pressure reactivity index (PRx) were not different between the intervention (CPP target = CPPopt) and control (CPP target = 60-70 mmHg) groups of the trial. This secondary analysis was performed to investigate whether: (1) in the intervention group, PRx was closer to PRxopt (PRx at CPPopt) values, indicating a more preserved reactivity, as opposed to in the control group; (2) in the intervention group, patients experienced lower hourly PRx when CPP was close to the CPPopt-based target. ⋯ Despite no statistically significant difference in the grand mean PRx, our results suggest that targeting CPPopt does provide a way of improving cerebrovascular reactivity in patients with TBI, offering a rational intervention for trials that address this issue. We also bring insight into aspects of the PRx/CPP relationship that should be considered for autoregulation-guided management for future clinical protocols and trials design.