Towards autoregulation-oriented management after traumatic brain injury: increasing the reliability and stability of the CPPopt algorithm
Journal of Clinical Monitoring and Computing, vol. 37, pp. 963–976
Abstract
PURPOSE: CPPopt denotes a Cerebral Perfusion Pressure (CPP) value at which the Pressure-Reactivity index, reflecting the global state of Cerebral Autoregulation, is best preserved. CPPopt has been investigated as a potential dynamically individualised CPP target in traumatic brain injury patients admitted in intensive care unit. The prospective bedside use of the concept requires ensured safety and reliability of the CPP recommended targets based on the automatically-generated CPPopt. We aimed to: Increase stability and reliability of the CPPopt automated algorithm by fine-tuning; perform outcome validation of the adjusted algorithm in a multi-centre TBI cohort. METHODS: ICM + software was used to derive CPPopt and fine-tune the algorithm. Parameters for improvement of the algorithm were selected based on qualitative and quantitative assessment of stability and reliability metrics. Patients enrolled in the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution cohort were included for retrospective validation. Yield and stability of the new algorithm were compared to the previous algorithm using Mann-U test. Area under the curves for mortality prediction at 6 months were compared with the DeLong Test. RESULTS: CPPopt showed higher stability (p < 0.0001), but lower yield compared to the previous algorithm [80.5% (70-87.5) vs 85% (75.7-91.2), p < 0.001]. Deviation of CPPopt could predict mortality with an AUC of [AUC = 0.69 (95% CI 0.59-0.78), p < 0.001] and was comparable with the previous algorithm. CONCLUSION: The CPPopt calculation algorithm was fine-tuned and adapted for prospective use with acceptable lower yield, improved stability and maintained prognostic power.
Authors 49
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Erta Beqiri corresponding
Affiliation as printed
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK. vb391@cam.ac.uk
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Affiliation as printed
Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Maastricht University Medical Centre · Maastricht University
Affiliation as printed
Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
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Affiliation as printed
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Maastricht University Medical Centre · Maastricht University
Affiliation as printed
Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
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Warsaw University of Technology · University of Cambridge
Affiliation as printed
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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University of Milan · Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico
Affiliation as printed
Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
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Affiliation as printed
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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University Hospital of North Norway · University of Cambridge
Affiliation as printed
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
Depart-ment of Physical Medicine and Rehabilitation, University hospital Northern Norway,
• CENTER-TBI High Resolution (HR ICU) Sub-Study Participants and Investigators
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Innsbruck Medical University · Universität Innsbruck · University of Cambridge
Affiliation as printed
Department of Neurology, Neurological Inten-sive Care Unit, Medical University of Innsbruck, Innsbruck, Austria,
Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Karolinska University Hospital · Maastricht University Medical Centre · Maastricht University
Affiliation as printed
Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden,
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Warsaw University of Technology · University of Pecs
Affiliation as printed
CENTER-TBI High Resolution
Department of Neurosur-gery, Medical School, University of Pécs, Hungary and Neurotrauma Research Group,
Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
János Szentágothai Research Centre, University of Pécs, Hungary,
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University of Cambridge · Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico · Addenbrooke's Hospital
Affiliation as printed
CENTER-TBI High Resolution
Brain Physics Lab, Division of Neurosurgery, Dept of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK,
Department of Anaesthesia and Critical Care,
Neuroscience Intensive Care Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
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University of Milan · Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico
Affiliation as printed
CENTER-TBI High Resolution
Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
Neuro ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy,
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Maastricht University · Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda
Affiliation as printed
CENTER-TBI High Resolution
NeuroIntensive Care, Niguarda Hospital, Milan, Italy,
School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
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Azienda Ospedaliera San Gerardo · University of Milano-Bicocca
Affiliation as printed
NeuroIntensive Care Unit , Department of Anesthesia & Intensive Care , ASST di Monza , Monza , Italy,
School of Medicine and Surgery , Università Milano Bicocca , Milano , Italy,
NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy,
School of Medicine and Surgery, Università Milano Bicocca, Milano, Italy,
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Affiliation as printed
Department of Neurosurgery , Medical Faculty RWTH Aachen University , Aachen , Germany,
Department of Neurosurgery, Medical Faculty RWTH Aachen University, Aachen, Germany,
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Affiliation as printed
Department of Neuro-surgery, University of Pecs and MTA-PTE Clinical Neuroscience MR Research Group and Janos Szentagothai Research Centre, University of Pecs, Hungarian Brain Research Program (Grant No. KTIA 13 NAP-A-II/8), Pecs, Hungary,
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Universitair Ziekenhuis Leuven · KU Leuven
Affiliation as printed
Department of Neurosurgery , University Hospi- tals Leuven , Leuven , Belgium,
Department of Neurosurgery, University Hospi-tals Leuven, Leuven, Belgium,
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University Hospital of North Norway
Affiliation as printed
Department of Anesthesiology and Intensive care , University Hospital Northern Norway , Tromso , Norway,
Department of Anesthesiology and Intensive care, University Hospital Northern Norway, Tromso, Norway,
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Innsbruck Medical University · Universität Innsbruck · University of Cambridge
Affiliation as printed
Department of Neurology , Neurological Inten- sive Care Unit , Medical University of Innsbruck , Innsbruck , Austria,
Division of Anaesthesia , University of Cambridge , Cambridge , UK
Department of Neurology, Neurological Inten-sive Care Unit, Medical University of Innsbruck, Innsbruck, Austria,
Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Sheffield Teaching Hospitals NHS Foundation Trust
Affiliation as printed
Neurointensive Care , Sheffield Teach- ing Hospitals NHS Foundation Trust , Sheffield , UK,
Neurointensive Care, Sheffield Teach-ing Hospitals NHS Foundation Trust, Sheffield, UK,
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Rigshospitalet · Capital Region of Denmark
Affiliation as printed
Departments of Neurology , Clinical Neurophysiology and Neuroanesthesiology , Region Hovedstaden Rigshospitalet , Copenhagen , Denmark,
Departments of Neurology, Clinical Neurophysiology and Neuroanesthesiology, Region Hovedstaden Rigshospitalet, Copenhagen, Denmark,
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Affiliation as printed
Depart- ment of Clinical Neuroscience , Neurosurgery , Umeå University , Umeå , Sweden,
Depart-ment of Clinical Neuroscience, Neurosurgery, Umeå University, Umeå, Sweden,
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Affiliation as printed
Department of Anaesthesiology , University Hospital of Aachen , Aachen , Germany,
Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany,
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Anaesthesia , University of Cambridge , Addenbrooke's Hospital , Cambridge , UK,
Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK,
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Affiliation as printed
Intensive Care Medicine , University Hos- pitals Leuven , Leuven , Belgium,
Intensive Care Medicine, University Hos-pitals Leuven, Leuven, Belgium,
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Rigshospitalet · Capital Region of Denmark
Affiliation as printed
Department Neuroanesthesiology , Region Hovedstaden Rigshospitalet , Copenhagen , Denmark,
Department Neuroanesthesiology, Region Hovedstaden Rigshospitalet, Copenhagen, Denmark,
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Karolinska University Hospital · Maastricht University Medical Centre · Maastricht University
Affiliation as printed
Department of Intensive Care Medicine , Maastricht University Medical Center+ , Maastricht , The Netherlands
Department of Neurosurgery & Anesthesia & intensive care medicine , Karolinska University Hospital , Stockholm , Sweden,
Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
Department of Neurosurgery & Anesthesia & intensive care medicine, Karolinska University Hospital, Stockholm, Sweden,
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Affiliation as printed
Hel- sinki University Central Hospital , Helsinki , Finland,
Hel-sinki University Central Hospital, Helsinki, Finland,
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Vall d'Hebron Hospital Universitari
Affiliation as printed
Department of Neurosurgery , Vall d'Hebron University Hospital , Barcelona , Spain,
Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain,
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Kaunas University of Technology · Vilnius University
Affiliation as printed
Department of Neurosurgery , Kaunas University of technology and Vilnius University , Vilnius , Lithuania,
Department of Neurosurgery, Kaunas University of technology and Vilnius University, Vilnius, Lithuania,
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Affiliation as printed
Hel- sinki University Central Hospital , Helsinki , Finland,
Hel-sinki University Central Hospital, Helsinki, Finland,
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Affiliation as printed
Department of Anaesthesia ,
Critical Care & Pain Medicine NHS Lothian & University of Edinburg, Edinburgh, UK,
Department of Anaesthesia,
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Kaunas University of Technology · Vilnius University
Affiliation as printed
Department of Neurosurgery , Kaunas University of technology and Vilnius University , Vilnius , Lithuania,
Department of Neurosurgery, Kaunas University of technology and Vilnius University, Vilnius, Lithuania,
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Affiliation as printed
Department of Anaesthesiology , University Hospital of Aachen , Aachen , Germany,
Department of Anaesthesiology, University Hospital of Aachen, Aachen, Germany,
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Vall d'Hebron Hospital Universitari
Affiliation as printed
Department of Neurosurgery , Vall d'Hebron University Hospital , Barcelona , Spain,
Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain,
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University Hospital Heidelberg · Klinikum Ludwigsburg
Affiliation as printed
CENTER-TBI High Resolution
Department of Neurosurgery , University Hospital Heidelberg , Heidelberg , Germany,
Klinik für Neurochirurgie , Klinikum Ludwigsburg , Ludwigsburg , Germany,
Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany,
Klinik für Neurochirurgie, Klinikum Ludwigsburg, Ludwigsburg, Germany,
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Affiliation as printed
CENTER-TBI High Resolution
) Sub-Study Participants and Investigators
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University of Turku · Turku University Hospital · Umeå University
Affiliation as printed
Perioperative Services,
Department of Radiation Sciences, Biomedical Engi-neering, Umea University, Umea, Sweden,
Perioperative Services, Intensive Care Medicine, and Pain Management , Turku University Central Hospital and University of Turku, Turku, Finland,
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Lithuanian University of Health Sciences
Affiliation as printed
Neuro- intensive Care Unit , Kaunas University of Health Sciences , Kaunas , Lithuania,
Neuro-intensive Care Unit, Kaunas University of Health Sciences, Kaunas, Lithuania,
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University of Turku · Turku University Hospital
Affiliation as printed
Rehabilitation and Brain Trauma , Turku University Cen- tral Hospital and University of Turku , Turku , Finland,
Rehabilitation and Brain Trauma, Turku University Cen-tral Hospital and University of Turku, Turku, Finland,
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University Hospital Heidelberg
Affiliation as printed
Department of Neurosurgery , University Hospital Heidelberg , Heidelberg , Germany,
Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany,
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University of Cambridge · Humboldt-Universität zu Berlin · University of Manitoba · Charité - Universitätsmedizin Berlin
Affiliation as printed
Neurologie, Neurochirurgie und Psychiatrie , Charité -Universitätsmedizin Berlin , Berlin , Germany , 33 Department of Neurosurgery, Kaunas University of Health Sciences, Kaunas, Lithuania, 34 Department of Neurosurgery, Charité -Universitätsmedizin Berlin, corporate member of Freie Uni- versität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany, 35 Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Azienda Ospedaliera San Gerardo
Affiliation as printed
NeuroIntensive Care Unit , Department of Anesthesia & Intensive Care , ASST di Monza , Monza , Italy,
NeuroIntensive Care Unit, Department of Anesthesia & Intensive Care, ASST di Monza, Monza, Italy,
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Affiliation as printed
János Szentágothai Research Centre , University of Pécs , Hungary,
) Sub-Study Participants and Investigators
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Affiliation as printed
János Szentágothai Research Centre , University of Pécs , Hungary,
) Sub-Study Participants and Investigators
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University Hospital Heidelberg · University of Pecs
Affiliation as printed
Department of Neurosurgery , University Hospital Heidelberg , Heidelberg , Germany,
Janos Szentagothai Research Centre , University of Pecs , Hungarian Brain Research Program (Grant No. KTIA 13 NAP-A- II/ 8) , Pecs , Hungary,
Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany,
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Anaesthesia , University of Cambridge , Addenbrooke's Hospital , Cambridge , UK,
Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK,
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