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      A Simple Method to Level the Transducer to the Tragus during Neurosurgical Procedures

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          ABSTRACT

          For patients who have suffered traumatic brain injury (TBI) or are planned for neurosurgical procedures, cerebral perfusion pressure (CPP) monitoring becomes essential for maintaining adequate cerebral blood flow. While measuring intra-arterial blood pressure, the transducer should be zeroed to the level of the tragus. Any erroneous measurement of CPP may lead to the failure of CPP-guided therapies. In neurosurgical patients, the head end of the patient is wholly draped and surrounded by the surgical personnel, which makes identifying the tragus and precise leveling of the transducer to the tragus from the foot end extremely difficult. To overcome this difficulty, we have devised a spirit level that can accurately confirm that the transducer is at the level of the tragus. The described device is easily assembled with the components easily available in the operation room. The device is regularly being used in our daily practice with excellent results.

          How to cite this article

          Nath SS, Nagar K, Nachimuthu N, et al. A Simple Method to Level the Transducer to the Tragus during Neurosurgical Procedures. J Acute Care 2024;3(2):91–92.

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          Cerebral perfusion pressure, intracranial pressure, and head elevation.

          W B Coley, Bettina Rosner (1986)
          Previous investigations have suggested that intracranial pressure waves may be induced by reduction of cerebral perfusion pressure (CPP). Since pressure waves were noted to be more common in patients with their head elevated at a standard 20 degrees to 30 degrees, CPP was studied as a function of head position and its effect upon intracranial pressure (ICP). In 18 patients with varying degrees of intracranial hypertension, systemic arterial blood pressure (SABP) was monitored at the level of both the head and the heart. Intracranial pressure and central venous pressure were assessed at every 10 degrees of head elevation from 0 degree to 50 degrees. For every 10 degrees of head elevation, the average ICP decreased by 1 mm Hg associated with a reduction of 2 to 3 mm Hg CPP. The CPP was not beneficially affected by any degree of head elevation. Maximal CPP (73 +/- 3.4 mm Hg (mean +/- standard error of the mean] always occurred with the head in a horizontal position. Cerebrospinal fluid pressure waves occurred in four of the 18 patients studied as a function of reduced CPP caused by head elevation alone. Thus, elevation of the head of the bed was associated with the development of CPP decrements in all cases, and it precipitated pressure waves in some. In 15 of the 18 patients, CPP was maintained by spontaneous 10- to 20-mm Hg increases in SABP, and pressure waves did not occur if CPP was maintained at 70 to 75 mm Hg or above. It is concluded that 0 degree head elevation maximizes CPP and reduces the severity and frequency of pressure-wave occurrence. If the head of the bed is to be elevated, then adequate hydration and avoidance of pharmacological agents that reduce SABP or prevent its rise are required to maximize CPP.
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            Calculation of cerebral perfusion pressure in the management of traumatic brain injury: joint position statement by the councils of the Neuroanaesthesia and Critical Care Society of Great Britain and Ireland (NACCS) and the Society of British Neurological Surgeons (SBNS)

            E. Thomas, M Czosnyka, P. Hutchinson (2015)
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              Inaccurate Blood Pressure Readings in the Intensive Care Unit: An Observational Study

              Brian Tse, Mark Burbridge, Richard Jaffe … (2018)
              Measuring and monitoring cerebral perfusion pressure (CPP) is important in the management of patients with certain neurological conditions. To accurately reflect blood pressure at the circle of Willis, the arterial line transducer should be leveled at the tragus. This study measured the relative distance of the transducer to the tragus in 100 intensive care unit (ICU) patients in the mixed ICU at our institution, of which 44 patients had a pressure-sensitive neurological diagnosis. For neurological patients, the average distance was 10.9 cm and for non-neurological patients, the average distance was 11.4 cm (p-value: 0.60). This suggests that the arterial line transducer was leveled at approximately the same level regardless of pathology, potentially leading to falsely elevated CPP readings in patients with pressure-sensitive neurological pathology.
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                Author and article information

                Journal
                Journal ID (publisher): JAC
                Title: Journal of Acute Care
                Abbreviated Title: J Acute Care
                Abbreviated Title: JAC
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Electronic): N/A
                Publication date (Print): May-August 2024
                Volume: 3
                Issue: 2
                Pages: 91-92
                Affiliations
                [1 ]Department of Anaesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
                [2 ]Department of Anaesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
                [3 ]Department of Anaesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
                [4 ]Department of Anaesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
                Author notes
                Soumya S Nath, Department of Anaesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9648935430, e-mail: soumyanath@ 123456rediffmail.com
                Article
                DOI: 10.5005/jp-journals-10089-0113
                SO-VID: f87abede-9b9f-435a-8637-ae02564847f7
                Copyright © Copyright © 2024; The Author(s).
                License:

                © The Author(s). 2024 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 07 March 2024
                Date accepted : 17 May 2024
                Date: 19 August 2024
                Categories
                Subject: HOW WE DO IT
                Custom metadata
                file-pdf jac-3-91.pdf

                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: Neurosurgical,Tragus,Transducer,Spirit level
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma
                Keywords: Neurosurgical, Tragus, Transducer, Spirit level

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