Monitoring of Optimal Cerebral Perfusion Pressure in Traumatic Brain Injured Patients Using a Multi-Window Weighting Algorithm

Abstract

Methods to identify an autoregulation guided "optimal'' cerebral perfusion pressure (CPPopt) for traumatic brain injury patients (TBI) have been reported through several studies. An important drawback of existing methodology is that CPPopt can be calculated only in similar to 50-60% of the monitoring time. In this study, we hypothesized that the CPPopt yield and the continuity can be improved significantly through application of a multi-window and weighting calculation algorithm, without adversely affecting preservation of its prognostic value. Data of 526 severe TBI patients admitted between 2003 and 2015 were studied. The multi-window CPPopt calculation was based on automated curve fitting in pressure reactivity index (PRx)-CPP plots using data from 36 increasing length time windows (2-8 h). The resulting matrix of CPPopts was then averaged in a weighted manner. The yield, continuity, and stability of CPPopt were studied. The difference between patients' actual CPP and CPPopt (DCPP) was calculated and the association with outcome was analyzed. Overall, the multi-window method demonstrated more continuous and stable presentation of CPPopt in this cohort. The new method resulted in a mean (+/- SE) CPPopt yield of 94%+/- 2.1%, as opposed to the previous single-window-based CPPopt yield of 51%+/- 0.94%. The stability of CPPopt across the whole monitoring period was significantly improved by using the new algorithm (p < 0.001). The relationship between DCPP according to the multi-window algorithm and outcome was similar to that for CPPopt calculated on the basis of a single window. In conclusion, this study validates the use of a new multi-window and weighting algorithm for significant improvement of CPPopt yield in TBI patients. This methodological improvement is essential for its clinical application in future CPPopt trials.