47
Cerebral Intraparenchymal Pressure Monitoring in Non-Traumatic Coma: Clinical Evaluation of a New Fibreoptic Device ByR.
c. TaskerandD.]. Matthew
Abstract Initial reporting and validation of the Camino miniaturised fibreoptic cerebral intraparenchymal pressure monitoring device has indicated that this tip transducing system (a) aIlows direct measurement of brain tissue pressure, (b) has a rapid response rate to intracranial changes and (c) correlates weIl with intraventricular pressure. However, there are no specific reports of this form of monitoring during non-traumatic coma in children, or anyevaluation of change in clinical practice when compared with experience of other forms of invasive intracranial pressure monitoring. Over a 5-year-period (1985-1989) on the General Paediatric Intensive Care Unit, 74 children with presumed raised intracranial pressure complicating nontraumatic coma have had invasive intracranial pressure monitoring with a variety of devices. An intraventricular catheter was used in 16 patients, a subdural catheter in 6 patients, a subarachnoid screw in 35 patients and a fibreoptic intraparenchymal catheter in 17 patients. In 1985 to 1986 our preferred technique was the subarachnoid screw (33/49 patients monitored). Between 1987 and 1989 we have mainly
Introduction In young children raised intracranial pressure (ICP) can be a feature of a variety of acute iIlnesses (1, 3, 5, 10). During the course of intensive care invasive measurement may be the only means of recognising this complication (5) and continuous monitoring the best guide to standard "cerebral protective" measures. In addition foIlowing of patient trends may provide useful information about treatment responsiveness and prognosis. A number of ICP monitoring systems are availahle for paediatric use and usual techniques include monitoring from intraventricular, subdural and subarachnoid spaces. Each of these have respective advantages, limitations and disadvanReceived March 19, 1990; accepted April 25, 1990 Neuropediatrics 22 (1991) 47-49 © Hippokrates Verlag Stuttgart
used the Camino fibreoptic intraparenchymal monitoring system (17/25 patients monitored). In the whole series there were no cases of acute haemorrhage related to monitoring and only one patient developed infection and in this child an intraventricular catheter was used. The experience with the fibreoptic system has been favourable and the technique for insertion does not require additional expertise in comparison with standard subarachnoid screw pressure monitoring. Therefore in young children with raised intracranial pressure complicating non-traumatic coma, cerebral fibreoptic intraparenchymal pressure monitoring should be used in preference to standard subarachnoid screw pressure monitoring. Furthermore because of the ease of insertion this can be considered a worthwhile alternative to intraventricular pressure monitoring, particularly in patients with smaIl or coIlapsed ventricles where ventriculostomy is expected to be difficult.
Keywords Cerebral intraparenchymal pressure - Nontraumatic coma
tages and decision about type of monitoring is usually based on experience, expertise and complication rate. In our previous practice the subarachnoid screw has been the preferred technique during non-traumatic coma (10) despite the reported problem of inaccuracy at higher levels of ICP (6, 8). The "gold standard", intraventricular pressure monitoring, is more invasive and ventriculostomy may not always be easily performed in patients with coIlapsed ventricles. This is of particular relevance in non-traumatic coma complicated by raised ICP, since in our experience diffuse cerebral CT scan changes with generalised loss of cerebrospinal fluid spaces is the usual finding (11). It was for reasons such as these, that a new fibreoptic cerebral intraparenchymal monitoring device (Camino OLM 110 ICP Monitoring System, Camino Laboratories, San Diego, USA) was developed (7). Laboratory and clinical validation have indicated that this monitoring device allows direct measurement of brain tissue pressure, has a rapid response rate to intracranial changes and correlates weIl with intraventricular pressure over a clinicaIly relevant period (2,4, 7).
Downloaded by: Universite Laval. Copyrighted material.
General Paediatric Intensive Care Unit, Hospital for Siek Children, Great Ormond Street, London, England
N europediatrics 22 (1991)
Since there has been little reportihg and evaluation of altered clinical practice using this form of monitoring during non-traumatic coma, this review highlights our experience.
Material and methods In a 5-year-period (1985-1989) 74 infants and children have undergone invasive ICP monitoring as part of the management of presumed raised ICP complicating nontraumatic coma. The clinical details of patients monitored between 1985 and 1986 have been previously reported (9-11). Between 1987 and 1989 17 children (aged 11 months to 15.5 years, median 3 years) were monitored using the miniaturised fibreoptic cerebral intraparenchymal pressure device (Camino system). In these 17 patients monitoring and acute management were carried out with reference to a previously described protocol (10). The diagnoses of these patients included central nervous system infection in 5, encephalopathy/encephalitis in 5, hypoxic/ischaemic encephalopathy in 6 and diabetic ketoacidosis in 1. Our experience with the intraparenchymal monitor was reviewed with reference to experience with other more standard forms of ICP monitoring. Insertion of the fibreoptic catheter was carried out on the intensive care unit. The catheter with the pressure transducing tip was introduced into the cerebral parenchyma through the centre of a bolt screwed into the cranium (Fig. 1). Only one passage of the catheter was required and the tip was inserted to an approximate depth of 5-15 mm. The 2.7 mm diameter right frontal burr hole necessary for this procedure was carried out according to the manufacturer's recommendations using strict aseptic technique. The sensitivity and linearity of each device is calibrated by the manufacturer and requires no manipulation. The zero or atmospheric balance was performed at the bedside before insertion. During the course of monitoring zero drift cannot be rechecked without removal of the catheter and cessation of monitoring with that device.
Fig. 1 Top: The Camino miniaturised fibreoptic, tip transducer, pressure monitoring catheter. Bottam: The catheter inserted through the centre of the subarachnoid bolt produced for affixing the catheter to the cranium.
R. C. TaskerandD.]. Matthew labia 1 tween
Experience with different forms of invasive ICP monitoring be-
1985 and 1989.
Type of monitoring
Number (complications)
1985-1986 Subarachnoid screw Subdural catheter Intraventricular catheter Intraparenchymal Camino
33 (0) 3 (0) 13 (l-infection)
1987-1989 2 (0) 3 (0) 3 (0)
17 (0)
Results In the 3 years (1987-1989) a total of 19 cerebral intraparenchymal fibreoptic catheter placements were carried out in 17 patients and none was complicated by acute haemorrhage or infection. Comparison of these findings with our experience of other forms of ICP monitoring during nontraumatic coma (1985-1989) is summarized in Table 1. Of the 74 patients, only one child developed infection related to monitoring and that was whilst using an intraventricular catheter. Acute haemorrhage has not been a complication in any patient. Using the Camino system a high fidelity pressure waveform was obtained in all patients and was maintained throughout the period of monitoring (range 1-10 days, median 3 days) (Fig. 2). Fibre breakages with resultant device malfunction occurred in two cases and were in the extracranial portion of the catheter. Following planned removal of working systems (17 catheters) drift from zero was less than 5 mm Hg in all cases.
Discussion Although this series is small, our clinical evaluation of cerebral intraparenchymal pressure monitoring in critically ill children indicates that compared with our experience of other forms of ICP monitoring complication rate is favourable. The Camino fibreoptic system has a high fidelity trace which is maintained throughout the period of monitoring without apparent dampening. The fibre breakages which occurred were early in our experience and were subsequently prevented by instruction on appropriate device handling. It is our impression that this form of monitoring has definite advantages over standard subarachnoid screw pressure monitoring which was our previously preferred technique. It is safe and requires only one passage of the catheter. Furthermore reported validation (2, 4, 7) has indicated that it correlates weIl with intraventricular pressure. However, its one disadvantage is that regular rechecking of zero drift, standard with intensive care monitoring of other physiological parameters, is not possible. In conclusion we believe that in young children with raised ICP complicating non-traumatic coma, cerebral intraparenchymal pressure monitoring is a safe technique and should be used in preference to standard subarachnoid screw pressure monitoring. Furthermore because catheter placement requires only one passage it may be an alternative to intraventricular pressure monitoring worth considering in patients with cranial CT scan features of small or collapsed ventricles, particularly if intraventricular catheter placement is not usually achieved with a "one pass" technique.
Downloaded by: Universite Laval. Copyrighted material.
48
Intraparenchymal Pressure Monitoring Day2
Oay 1
Neuropediatrics 22 (1991)
Acknowledgments
Day3
50
49
We are grateful to Messrs. N. Grant and R. Hayward and thejunior neurosurgieal staff at the Hospitals for Siek Children, Great Ormond Street.
ICP 25 mmHg
References
o 1
100
Balakrishnan, G., C. H. Skeoch,]. B. Stephenson, R. C. Mc William, D. Hallworth,]. F. Sinclair: Intracranial pressure monitoring in a group of
critically ill children (letter). Arch. Dis. Child. 64 (1989) 427 Chambers, 1. R., A. D. Mendelow,]. Sinar, P. Modha: Clinical Evaluation of the Catheter Tipped Camino Transducer Inserted via a Subdural Screw. In Hoff,]. T, A. L. Betz: Intracranial Pressure VII. Berlin, Heidelberg, Springer-Verlag (1989) 27-30 3 Goitein, K.]., P. Fainmesser, H. Sohmer: Cerebral perfusion pressure and auditory brainstem responses in childhood CNS diseases. Am. J. Dis. Child. 137 (1983) 777-781 4 Leggate,]. R. S., 1. R. Piper, 1. Robertson, A. Lawson,]. D. Miller: Clinical and Laboratory Evaluation ofthe Camino Intracranial Pressure Monitoring System. In Hoff,]. T, A. L. Betz. Intracranial Pressure VII. Berlin, Heidelberg, Springer-Verlag (1989) 31-34 5 Mickell, ]. ]., D. H. Reigel, D. R. Cook, R. E. Binda, P. Safar: Intracranial pressure: monitoring and normalization therapy in children. Pediatrics 59 (1977) 606-613 6 Miller,]. D., H. Bobo,]. P. Kapp: Inaccurate pressure readings for subarachnoid bolts. Neurosurgery 2 (1986) 253-255 7 Ostrup, R. C., T G. Luerssen, L. F. Marshall, M. H. Zornow: Continuous monitoring of intracranial pressure with a miniaturized fiberoptic device. J. Neurosurg. 67 (1987) 206-209 8 Rowan,]. 0., A. D. Mendelow, L. Murray, A. Kerr: Clinical Comparison of Intracranial Pressure Measurement Provided by Subdural Screws and Ventricular Catheters. In Ishii, S., H. Nagai, M. Brock: Intracranial Pressure V. Berlin, Heidelberg, Springer-Verlag (1983) 110-115 9 Tasker, R. C., S. Boyd, A. Harden, D.]. Matthew: Monitoring in nontraumatic comall: electroencephalography.Arch.Dis.Child. 63 (1988) 895-899 10 Tasker, R. C., D.]. Matthew, P. Helms, R. Dinwiddie, S. Boyd: Monitoring in non-traumatic coma I: invasive intracranial measurement. Arch. Dis. Child. 63 (1988) 888-894 11 Tasker, R. C., D.]. Matthew, B. Kendall: Computed tomography in the assessment of raised intracranial pressure in non-traumatic coma. Neuropediatrics 21 (1990) 91-94
BP 50 mmHg
I
I
1 second
Day3 50
ICP 25
mmHg
o 100
BP 50 mmHg
I
I
10 minutes Fig. 2 Top: Simultaneous ICP monitoring using the fibreoptic intraparenchymal catheter and blood pressure (BP) monitoring from an intraarterialline taken from days 1, 2 and 3 of monitoring in a child. ICP waveform peak and trough components are shown at different mean pressures. Bottom: Continuous trace of ICP and BP at compressed paper speed (mean values - first part of trace, peak and trough values - second part of trace).
Dr. R. C. Tasker Dept. of Anesthesiology and Critical Care Medicine Johns Hopkins Hospital 600 North Wolfe Street Baltimore, MD 21205 U.S.A.
Downloaded by: Universite Laval. Copyrighted material.
2
Cerebral Intraparenchymal Pressure Monitoring in Non-Traumatic Coma: Clinical Evaluation of a New Fibreoptic Device ByR.
c. TaskerandD.]. Matthew
Abstract Initial reporting and validation of the Camino miniaturised fibreoptic cerebral intraparenchymal pressure monitoring device has indicated that this tip transducing system (a) aIlows direct measurement of brain tissue pressure, (b) has a rapid response rate to intracranial changes and (c) correlates weIl with intraventricular pressure. However, there are no specific reports of this form of monitoring during non-traumatic coma in children, or anyevaluation of change in clinical practice when compared with experience of other forms of invasive intracranial pressure monitoring. Over a 5-year-period (1985-1989) on the General Paediatric Intensive Care Unit, 74 children with presumed raised intracranial pressure complicating nontraumatic coma have had invasive intracranial pressure monitoring with a variety of devices. An intraventricular catheter was used in 16 patients, a subdural catheter in 6 patients, a subarachnoid screw in 35 patients and a fibreoptic intraparenchymal catheter in 17 patients. In 1985 to 1986 our preferred technique was the subarachnoid screw (33/49 patients monitored). Between 1987 and 1989 we have mainly
Introduction In young children raised intracranial pressure (ICP) can be a feature of a variety of acute iIlnesses (1, 3, 5, 10). During the course of intensive care invasive measurement may be the only means of recognising this complication (5) and continuous monitoring the best guide to standard "cerebral protective" measures. In addition foIlowing of patient trends may provide useful information about treatment responsiveness and prognosis. A number of ICP monitoring systems are availahle for paediatric use and usual techniques include monitoring from intraventricular, subdural and subarachnoid spaces. Each of these have respective advantages, limitations and disadvanReceived March 19, 1990; accepted April 25, 1990 Neuropediatrics 22 (1991) 47-49 © Hippokrates Verlag Stuttgart
used the Camino fibreoptic intraparenchymal monitoring system (17/25 patients monitored). In the whole series there were no cases of acute haemorrhage related to monitoring and only one patient developed infection and in this child an intraventricular catheter was used. The experience with the fibreoptic system has been favourable and the technique for insertion does not require additional expertise in comparison with standard subarachnoid screw pressure monitoring. Therefore in young children with raised intracranial pressure complicating non-traumatic coma, cerebral fibreoptic intraparenchymal pressure monitoring should be used in preference to standard subarachnoid screw pressure monitoring. Furthermore because of the ease of insertion this can be considered a worthwhile alternative to intraventricular pressure monitoring, particularly in patients with smaIl or coIlapsed ventricles where ventriculostomy is expected to be difficult.
Keywords Cerebral intraparenchymal pressure - Nontraumatic coma
tages and decision about type of monitoring is usually based on experience, expertise and complication rate. In our previous practice the subarachnoid screw has been the preferred technique during non-traumatic coma (10) despite the reported problem of inaccuracy at higher levels of ICP (6, 8). The "gold standard", intraventricular pressure monitoring, is more invasive and ventriculostomy may not always be easily performed in patients with coIlapsed ventricles. This is of particular relevance in non-traumatic coma complicated by raised ICP, since in our experience diffuse cerebral CT scan changes with generalised loss of cerebrospinal fluid spaces is the usual finding (11). It was for reasons such as these, that a new fibreoptic cerebral intraparenchymal monitoring device (Camino OLM 110 ICP Monitoring System, Camino Laboratories, San Diego, USA) was developed (7). Laboratory and clinical validation have indicated that this monitoring device allows direct measurement of brain tissue pressure, has a rapid response rate to intracranial changes and correlates weIl with intraventricular pressure over a clinicaIly relevant period (2,4, 7).
Downloaded by: Universite Laval. Copyrighted material.
General Paediatric Intensive Care Unit, Hospital for Siek Children, Great Ormond Street, London, England
N europediatrics 22 (1991)
Since there has been little reportihg and evaluation of altered clinical practice using this form of monitoring during non-traumatic coma, this review highlights our experience.
Material and methods In a 5-year-period (1985-1989) 74 infants and children have undergone invasive ICP monitoring as part of the management of presumed raised ICP complicating nontraumatic coma. The clinical details of patients monitored between 1985 and 1986 have been previously reported (9-11). Between 1987 and 1989 17 children (aged 11 months to 15.5 years, median 3 years) were monitored using the miniaturised fibreoptic cerebral intraparenchymal pressure device (Camino system). In these 17 patients monitoring and acute management were carried out with reference to a previously described protocol (10). The diagnoses of these patients included central nervous system infection in 5, encephalopathy/encephalitis in 5, hypoxic/ischaemic encephalopathy in 6 and diabetic ketoacidosis in 1. Our experience with the intraparenchymal monitor was reviewed with reference to experience with other more standard forms of ICP monitoring. Insertion of the fibreoptic catheter was carried out on the intensive care unit. The catheter with the pressure transducing tip was introduced into the cerebral parenchyma through the centre of a bolt screwed into the cranium (Fig. 1). Only one passage of the catheter was required and the tip was inserted to an approximate depth of 5-15 mm. The 2.7 mm diameter right frontal burr hole necessary for this procedure was carried out according to the manufacturer's recommendations using strict aseptic technique. The sensitivity and linearity of each device is calibrated by the manufacturer and requires no manipulation. The zero or atmospheric balance was performed at the bedside before insertion. During the course of monitoring zero drift cannot be rechecked without removal of the catheter and cessation of monitoring with that device.
Fig. 1 Top: The Camino miniaturised fibreoptic, tip transducer, pressure monitoring catheter. Bottam: The catheter inserted through the centre of the subarachnoid bolt produced for affixing the catheter to the cranium.
R. C. TaskerandD.]. Matthew labia 1 tween
Experience with different forms of invasive ICP monitoring be-
1985 and 1989.
Type of monitoring
Number (complications)
1985-1986 Subarachnoid screw Subdural catheter Intraventricular catheter Intraparenchymal Camino
33 (0) 3 (0) 13 (l-infection)
1987-1989 2 (0) 3 (0) 3 (0)
17 (0)
Results In the 3 years (1987-1989) a total of 19 cerebral intraparenchymal fibreoptic catheter placements were carried out in 17 patients and none was complicated by acute haemorrhage or infection. Comparison of these findings with our experience of other forms of ICP monitoring during nontraumatic coma (1985-1989) is summarized in Table 1. Of the 74 patients, only one child developed infection related to monitoring and that was whilst using an intraventricular catheter. Acute haemorrhage has not been a complication in any patient. Using the Camino system a high fidelity pressure waveform was obtained in all patients and was maintained throughout the period of monitoring (range 1-10 days, median 3 days) (Fig. 2). Fibre breakages with resultant device malfunction occurred in two cases and were in the extracranial portion of the catheter. Following planned removal of working systems (17 catheters) drift from zero was less than 5 mm Hg in all cases.
Discussion Although this series is small, our clinical evaluation of cerebral intraparenchymal pressure monitoring in critically ill children indicates that compared with our experience of other forms of ICP monitoring complication rate is favourable. The Camino fibreoptic system has a high fidelity trace which is maintained throughout the period of monitoring without apparent dampening. The fibre breakages which occurred were early in our experience and were subsequently prevented by instruction on appropriate device handling. It is our impression that this form of monitoring has definite advantages over standard subarachnoid screw pressure monitoring which was our previously preferred technique. It is safe and requires only one passage of the catheter. Furthermore reported validation (2, 4, 7) has indicated that it correlates weIl with intraventricular pressure. However, its one disadvantage is that regular rechecking of zero drift, standard with intensive care monitoring of other physiological parameters, is not possible. In conclusion we believe that in young children with raised ICP complicating non-traumatic coma, cerebral intraparenchymal pressure monitoring is a safe technique and should be used in preference to standard subarachnoid screw pressure monitoring. Furthermore because catheter placement requires only one passage it may be an alternative to intraventricular pressure monitoring worth considering in patients with cranial CT scan features of small or collapsed ventricles, particularly if intraventricular catheter placement is not usually achieved with a "one pass" technique.
Downloaded by: Universite Laval. Copyrighted material.
48
Intraparenchymal Pressure Monitoring Day2
Oay 1
Neuropediatrics 22 (1991)
Acknowledgments
Day3
50
49
We are grateful to Messrs. N. Grant and R. Hayward and thejunior neurosurgieal staff at the Hospitals for Siek Children, Great Ormond Street.
ICP 25 mmHg
References
o 1
100
Balakrishnan, G., C. H. Skeoch,]. B. Stephenson, R. C. Mc William, D. Hallworth,]. F. Sinclair: Intracranial pressure monitoring in a group of
critically ill children (letter). Arch. Dis. Child. 64 (1989) 427 Chambers, 1. R., A. D. Mendelow,]. Sinar, P. Modha: Clinical Evaluation of the Catheter Tipped Camino Transducer Inserted via a Subdural Screw. In Hoff,]. T, A. L. Betz: Intracranial Pressure VII. Berlin, Heidelberg, Springer-Verlag (1989) 27-30 3 Goitein, K.]., P. Fainmesser, H. Sohmer: Cerebral perfusion pressure and auditory brainstem responses in childhood CNS diseases. Am. J. Dis. Child. 137 (1983) 777-781 4 Leggate,]. R. S., 1. R. Piper, 1. Robertson, A. Lawson,]. D. Miller: Clinical and Laboratory Evaluation ofthe Camino Intracranial Pressure Monitoring System. In Hoff,]. T, A. L. Betz. Intracranial Pressure VII. Berlin, Heidelberg, Springer-Verlag (1989) 31-34 5 Mickell, ]. ]., D. H. Reigel, D. R. Cook, R. E. Binda, P. Safar: Intracranial pressure: monitoring and normalization therapy in children. Pediatrics 59 (1977) 606-613 6 Miller,]. D., H. Bobo,]. P. Kapp: Inaccurate pressure readings for subarachnoid bolts. Neurosurgery 2 (1986) 253-255 7 Ostrup, R. C., T G. Luerssen, L. F. Marshall, M. H. Zornow: Continuous monitoring of intracranial pressure with a miniaturized fiberoptic device. J. Neurosurg. 67 (1987) 206-209 8 Rowan,]. 0., A. D. Mendelow, L. Murray, A. Kerr: Clinical Comparison of Intracranial Pressure Measurement Provided by Subdural Screws and Ventricular Catheters. In Ishii, S., H. Nagai, M. Brock: Intracranial Pressure V. Berlin, Heidelberg, Springer-Verlag (1983) 110-115 9 Tasker, R. C., S. Boyd, A. Harden, D.]. Matthew: Monitoring in nontraumatic comall: electroencephalography.Arch.Dis.Child. 63 (1988) 895-899 10 Tasker, R. C., D.]. Matthew, P. Helms, R. Dinwiddie, S. Boyd: Monitoring in non-traumatic coma I: invasive intracranial measurement. Arch. Dis. Child. 63 (1988) 888-894 11 Tasker, R. C., D.]. Matthew, B. Kendall: Computed tomography in the assessment of raised intracranial pressure in non-traumatic coma. Neuropediatrics 21 (1990) 91-94
BP 50 mmHg
I
I
1 second
Day3 50
ICP 25
mmHg
o 100
BP 50 mmHg
I
I
10 minutes Fig. 2 Top: Simultaneous ICP monitoring using the fibreoptic intraparenchymal catheter and blood pressure (BP) monitoring from an intraarterialline taken from days 1, 2 and 3 of monitoring in a child. ICP waveform peak and trough components are shown at different mean pressures. Bottom: Continuous trace of ICP and BP at compressed paper speed (mean values - first part of trace, peak and trough values - second part of trace).
Dr. R. C. Tasker Dept. of Anesthesiology and Critical Care Medicine Johns Hopkins Hospital 600 North Wolfe Street Baltimore, MD 21205 U.S.A.
Downloaded by: Universite Laval. Copyrighted material.
2
