The LICOX System

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LICOXTheSystemBrain Tissue OxygenMonitoring SystemProduct PresentationNS1581-09/07

What is the LICOX system? Measures interstitial braintissue oxygenation (PbtO2) inmmHg and braintemperature ( C) Probe insertedapproximately 35mm belowthe dura into the whitematter of the brain PbtO2 used in conjunctionwith current ICP/CPPmonitoring methods11/2/20072

Who needs the LICOX system?Patients at risk fordeveloping cerebralhypoxia or ischemiaHead trauma patientsAneurysm patientsSubarachnoidhemorrhage patientsStroke patients 2007 Dr. Marcos Tatagiba. Reprinted with permission.11/2/20073

When is the LICOX system placed? Within the first 24-48hours of injury– The sooner cerebralhypoxia is detected, thebetter secondary injurycan be prevented Generally, when an ICPcatheter is required, aLICOX probe shouldbe considered11/2/20074

How is the LICOX system placed? Can be either bolted or tunneled Can be placed independently orwith an ICP catheter Requires minimal additionaleffort Does not need to be zeroed priorto placement, SMART card isincluded with each O2 probewith all calibration data Monitor need not be presentwhen placing in the OR11/2/20075

Where is the LICOX system placed? Placement is up toclinical discretion The idea is to preventSECONDARY injuryby ensuring livingtissue is receivingadequate oxygen11/2/2007 LICOX probe can beplaced in either the injuredside or non-injured side ofbrain Should not be placeddirectly into a lesion6

What are the probe options? BOLTEDDouble Lumen – Camino ICPchannel and LICOX PMOcatheter channel (IP2P) TUNNELEDLicox PMO combined oxygenand temperature catheter (IT2) Probe kits come withrequired drill bits and otheraccessories11/2/20077

How accurate are the probes?Oxygen Accuracy:PbtO2 0-20 mmHg accuracy is 2 mmHgPbtO2 21-50 mmHg accuracy is 10%PbtO2 51-150 mmHg accuracy is 13%Temperature Accuracy: 0.2 C11/2/20078

What about the nursing staff? Simple monitor set-upand use The monitor displaysa digital oxygen andtemperature reading Alarms are managedthrough a connectionto the bedside monitor11/2/20079

What is a “normal” reading? Normal: 25-35 mmHg Risk of death increases– 15 mmHg for 30 minutes– 10 mmHg for 10 minutes PbtO2 5 mmHg– high mortality PbtO2 2mmHg - neuronal death11- Bardt T, Unterberg A, et al. Monitoring of brain tissue PO2 in traumatic brain injury: effect ofcerebral hypoxia on outcome. Acta Neurochirurgica.1998;71(Suppl):153-156.11/2/200710

How is patient outcome affected? Its been found:– Head injured patients who undergo aggressive therapy tomaintain ICP/CPP at normal levels still experience periodsof severe brain hypoxia1– Interventions previously thought to improve tissueoxygenation may improve ICP and CPP but actuallydecrease PbtO221. Bardt T, Unterberg A, et al. Monitoring of brain tissue PO2 in traumatic brain injury: effectof cerebral hypoxia on outcome. Acta Neurochirurgica.1998;71(Suppl):153-156.2. Zauner A, Doppenberg E, et al. Extended neuromonitoring: new therapeutic opportunities?Neurological Research. 1998;20(Suppl 1):85-90.11/2/200711

How is patient outcome affected? The PbtO2 number can provide:– Notification of hypoxic episodes– Independent predictors of unfavorable outcome anddeath1 Treatments to maintain PbtO2 correspond to more favorablepatient outcomes21. Zauner A, Doppenberg E, et al. Extended neuromonitoring: new therapeuticopportunities? Neurological Research. 1998;20(Suppl 1):85-90.2. Valadka A, Gopinath S, et al. Relationship of brain tissue PO2 to outcome after severehead injury. Critical Care Medicine. 1998;26(9):1576-1581.11/2/200712

Is the LICOX system cost-efficient? Added costs the Licox system are justified bysignificantly improvedoutcomes Implementation of newprotocols using PbtO2– Improve patient care1– Better utilize resources1– Probable reduction of Ventilator days1,2 ICU days1,2 Overall hospital days1,21. Spain D, McIlvoy L, Fix S, et al. Effect of clinical pathway for severe traumatic braininjury on resource utilization. The Journal of Trauma. 1998;45(1):101-105.2. Simons R, Eliopoulos V, Laflamme D, Brown D. Impact on process of trauma caredelivery 1 year after introduction of trauma program in a provincial trauma center. TheJournal of Trauma. 1999;46(5):811-816.11/2/200713

How is the LICOX system different thana Jugular Venous Bulb? Jugular bulb oximetry, SjvO2, measures oxygensaturation of venous blood– Measures global oxygen reduction– Cannot identify regional cerebral ischemia– may lead to secondary injury1,21. Clay H. Validity and reliability of the SjO2 catheter in neurologically impairedpatients: A critical review of the literature. Journal of Neuroscience Nursing.2000;32(4):194-203.2. Mayberg T, Lam A. Jugular bulb oximetry for the monitoring of cerebral blood flowand metabolism. Neurosurgery Clinics of North America. 1996;7(4):755-765.11/2/200714

How is LICOX different than aJugular Venous Bulb? SjvO2 measurements are shown to be unreliable– Good quality data are only obtained about 50% of theplacement time1,2,3– SjvO2 is difficult to use in children due to small vein size41. Clay H. Validity and reliability of the SjO2 catheter in neurologically impaired patients: Acritical review of the literature. Journal of Neuroscience Nursing. 2000;32(4):194-203.2. Kiening K, et al. Monitoring of cerebral oxygenation in patients with severe head injuries:Brain tissue PO2 versus jugular vein oxygen saturation. Journal of Neurosurgery.1996;85:751-7573. Meixensberger J. et al. Multimodality hemodynamic neuromonitoring - Quality andconsequences for therapy of severely head injurted patients. Acta Neurochirugica.1998;71(Suppl):260-262.4. Palmer S, et al. The impact on outcomes in a community hospital setting of using the AANStraumatic brain injury guidelines. The Journal of Trauma. 2001;50(4):657-664.11/2/200715

A few institutions that have published clinicalstudies with the LICOX systems: Mission Hospital– Mission Viejo, CA Harborview– Seattle, WA Creighton University– Omaha, NE University of PennsylvaniaHospital– Philadelphia, PA11/2/200716

Thank you for your time!Please contact us anytime should you have anyfurther questions.

ReferencesBardt T, Unterberg A, et al. Monitoring of brain tissue PO2 intraumatic brain injury: effect of cerebral hypoxia on outcome. ActaNeurochirurgica.1998;71(Suppl):153-156.Clay H. Validity and reliability of the SjO2 catheter in neurologicallyimpaired patients: A critical review of the literature. Journal ofNeuroscience Nursing. 2000;32(4):194-203.Mayberg T, Lam A. Jugular bulb oximetry for the monitoring ofcerebral blood flow and metabolism. Neurosurgery Clinics of NorthAmerica. 1996;7(4):755-765.11/2/200718

References (cont.)Kiening K, et al. Monitoring of cerebral oxygenation in patients withsevere head injuries: Brain tissue PO2 versus jugular vein oxygensaturation. Journal of Neurosurgery. 1996;85:751-757Meixensberger J. et al. Multimodality hemodynamic neuromonitoringQuality and consequences for therapy of severely head injurtedpatients. Acta Neurochirugica. 1998;71(Suppl):260-262.Palmer S, et al. The impact on outcomes in a community hospitalsetting of using the AANS traumatic brain injury guidelines. TheJournal of Trauma. 2001;50(4):657-664.11/2/200719

References (cont.)Prasad S. et al. Cerebral oxygenation in major pediatric trauma:Its relevance to trauma severity scores and outcomes. Paperpresented at: 35th Annual Meeting of the American PediatricSurgical Associtation; May 27-30, 2004; Ponte Vedra Beach, Fla.Simons R, Eliopoulos V, Laflamme D, Brown D. Impact onprocess of trauma care delivery 1 year after introduction oftrauma program in a provincial trauma center. The Journal ofTrauma. 1999;46(5):811-816.11/2/200720

References (cont.)Spain D, McIlvoy L, Fix S, et al. Effect of clinical pathway forsevere traumatic brain injury on resource utilization. TheJournal of Trauma. 1998;45(1):101-105.Stiefel, M., et al. Reduced mortality rate in patients with severetraumatic brain injury treated with brain tissue oxygenmonitoring. J Neurosurg. 2005;103:805-811.Valadka A, Gopinath S, et al. Relationship of brain tissue PO2to outcome after severe head injury. Critical Care Medicine.1998;26(9):1576-1581.11/2/200721

References (cont.)Zauner A, Doppenberg E, et al. Extended neuromonitoring: newtherapeutic opportunities? Neurological Research.1998;20(Suppl 1):85-90.11/2/200722

developing cerebral hypoxia or ischemia Head trauma patients Aneurysm patients Subarachnoid hemorrhage patients . – Head injured patients who undergo aggressive therapy to . cerebral blood flow and metabolism. Neurosurgery Clinics of North America. 1996;7(4):755-765. 11/2/2007 19

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