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Introduction ⬇

Brain tissue oxygen (PbtO2) monitoring measures oxygen delivery to the cerebral tissue. It can help identify cerebral ischemia and hypoxia in patients with a brain tumor, traumatic brain injury, stroke, or aneurysmal or traumatic subarachnoid hemorrhage, as well as those at risk for secondary brain injury.1 Complications that result in cerebral hypoxia, including elevated intracranial pressure (ICP), shivering, agitation, seizures, fever, hypotension, hypovolemia, anemia, and hypoxia, are common causes of secondary brain injuries. Cerebral hypoxia, in turn, can lead to cerebral ischemia.

Use of PbtO2 monitoring with ICP monitoring detects early changes in ICP and PbtO2 so that treatment interventions can occur before secondary brain injury occurs. Normal values for PbtO2 range from 20 to 35 mm Hg.1 Contraindications to PbtO2 monitoring include anticoagulation therapy, insertion site infection, and coagulopathy.1

A practitioner inserts a PbtO2 probe through an intracranial bolt in a burr hole. Alternatively, the practitioner may tunnel the probe under the scalp using a probe guide and trocar. When used with an intracranial bolt, the system measures ICP, PbtO2, and brain tissue temperature. The practitioner determines the insertion method and placement location after studying a computed tomography (CT) scan of the patient’s brain and considering the patient’s diagnosis.2 (See Brain tissue oxygen monitoring systems.)

Equipment ⬆ ⬇

Equipment

Sterile gloves • sterile gowns • sterile drapes • goggles and mask or mask with face shield • surgical head covers • antiseptic solution • 4" × 4" (10-cm × 10-cm) gauze • PbtO2 monitor • connecting cables from the monitor to the patient • cranial access tray • PbtO2 probe (with smart card if using a Licox monitoring system) • sterile occlusive dressing • transparent adhesive dressing • cardiopulmonary monitor • pulse oximeter and probe • blood pressure monitoring equipment • prescribed sedative • prescribed analgesia • Optional: electric or battery-operated hair clippers with a single-use head or a reusable head that can be disinfected, tape, arm board, towels, washcloths, intracranial bolt system.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility. Gather a PbtO2 monitor and plug it into an AC wall outlet, and then attach the cables to the PbtO2 monitor. Some monitors and cables are color-coded.

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s orders.
  • Review the patient’s medical record for allergies to prescribed medications or antiseptic solution and any contraindications to the procedure.1
  • Gather the necessary equipment and supplies.
  • Confirm that informed consent has been obtained and that the signed consent form is in the patient’s medical record.1,2,3,4,5
  • Conduct a preprocedure verification to make sure that all relevant documentation, related information, and equipment are available and matched correctly to the patient’s identifiers.1,6,7
  • Verify that ordered laboratory and imaging studies have been completed and that the results are in the patient’s medical record. Notify the practitioner of any unexpected results.
  • Perform hand hygiene.8,9,10,11,12,13
  • Confirm the patient’s identity using at least two patient identifiers.14
  • Provide privacy.15,16,17,18
  • Explain the procedure to the patient and family (if appropriate) according to their communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.19. Answer any questions to increase their understanding of the information you provided.
  • Verify that the practitioner has marked the insertion site using an unambiguous mark according to the method determined by your ­facility.20
  • Assess the patient’s neurologic status before insertion so that you can recognize any changes during and after insertion of the PbtO2 probe.1
  • Attach the patient to a cardiac monitor, a pulse oximeter, and blood pressure monitoring equipment, and obtain measurements to serve as a baseline for comparison during and after the procedure. Make sure that alarm limits are set appropriately and that alarms are turned on, functioning properly, and audible to staff.21,22,23,24
  • Before beginning the insertion procedure, administer analgesia, sedation, or both, as ordered, following safe medication administration practices, to facilitate the insertion process.25,26,27,28
  • Keep the door to the room closed to restrict traffic into the room and the subsequent risk of site contamination during insertion.29
  • Prepare the equipment, being careful not to contaminate the sterile field. Label all medications, medication containers, and other solutions on and off the sterile field while maintaining sterility of the sterile field.30
  • Raise the patient’s bed to waist level before providing patient care to prevent caregiver back strain.31
  • Elevate the head of the bed to 30 degrees and place the patient’s head in a neutral position. This position helps decrease ICP by promoting jugular venous outflow, which provides for optimal insertion accessibility.1,29
  • Perform hand hygiene.8,9,10,11,12,13
  • Immobilize the patient’s head to prevent movement and facilitate device insertion.29
  • Braid or clip the patient’s hair. If you’re clipping hair, use tape to remove residual hair clippings.29
  • Perform hand hygiene.8,9,10,11,12,13
  • Assist the practitioner with putting on a surgical head cover, a mask, protective eyewear, a sterile gown, and sterile gloves, as necessary. Put on the same personal protective equipment.29,32,33
  • Assist the practitioner with site preparation using antiseptic solution to prepare the patient for a sterile procedure. Use antiseptic solution to clean the intended insertion site using a circular motion.29 Make sure that the antiseptic is dry before the practitioner starts the incision.1

NURSING ALERT Use of chlorhexidine is controversial because some studies suggest it’s neurotoxic.1

  • Assist the practitioner with draping the patient’s head, neck, and chest to maintain a sterile field.1,29
  • Conduct a time-out immediately before starting the procedure to perform a final assessment that the correct patient, site, positioning, and procedure are identified and that all relevant information and necessary equipment are available.29,34
  • Assist the practitioner with opening sterile trays, packaged probes (with a smart card if using a Licox monitor), and other equipment to help maintain a sterile environment and provide efficiency.1
  • Turn on the PbtO2 monitor and follow the manufacturer’s guidelines to prepare the monitor.1
  • If you are using a Licox monitor, place the smart card into the card slot located on the front of the monitor. This monitor requires the smart card numbers to match those on the oxygen probe that the practitioner will insert.1
  • During insertion, continually monitor the patient’s heart rate and rhythm, respiratory rate, and pulse oximetry; frequently monitor blood pressure; and perform neurologic assessments every 15 minutes to ensure prompt recognition and treatment of neurologic changes.1,29
  • If applicable, assist the practitioner with intracranial bolt insertion, which may occur before or after PbtO2 probe insertion. (See the "Intracranial pressure monitoring" procedure.)
  • Assist the practitioner with insertion of the temperature and oxygen probes.
  • After the practitioner inserts the temperature and oxygen probes, connect them to the monitor cables.
  • Look at the monitor for temperature and PbtO2 values. Note that temperature values should be accurate immediately, but PbtO2 values can take as long as 2 hours to be accurate, because brain tissue settles after the trauma of probe placement.1
  • If the bedside monitor allows, use a cable to capture the values from the PbtO2 monitor to the bedside monitor to allow integration between monitoring systems.
  • Make sure that all monitor alarm limits are set appropriately for the patient’s current condition, and that the alarms are turned on, functioning properly, and audible to staff.21,22,23,24
  • Apply a sterile occlusive dressing at the insertion site to reduce the risk of infection.1,29
  • Secure the PbtO2 monitor cables to prevent tension at the insertion site.1 Anchor cables from the patient’s head and shoulder with a transparent adhesive dressing. Make sure that the entire setup is supported but that enough slack is provided for you to turn and move the patient. Consider using an arm board to support and secure the cables1 and placing towels or washcloths under the setup for support. Make sure that the cables aren’t dragging on the ground.
  • After the patient’s brain tissue has adjusted to device insertion, maintain the patient’s PbtO2 value between 20 and 35 mm Hg, or as ordered by the practitioner.1 (See the "Brain tissue oxygen monitoring and care" procedure.)
  • Reassess and respond to the patient’s pain by evaluating the response to treatment and progress toward pain management goals. Assess for adverse reactions and risk factors for adverse events that may result from treatment.35
  • Return the bed to the lowest possible position to prevent falls and maintain patient safety.36
  • Discard used supplies in the appropriate receptacles.32,33
  • Remove and discard your personal protective equipment.32,33
  • Perform hand hygiene.8,9,10,11,12,13
  • Document the procedure.37,38,39,40

Special Considerations ⬆ ⬇

Special considerations
  • The Joint Commission has issued a sentinel event alert concerning medical device alarm safety, because alarm-related events have been associated with permanent loss of function or death. Among the major contributing factors were improper alarm settings, alarm settings turned off inappropriately, and alarm signals that are inaudible to staff. Make sure that alarm limits are set appropriately, and that alarms are turned on, functioning properly, and audible to staff. Follow facility guidelines for preventing alarm fatigue.23
  • PbtO2 probes are compatible with magnetic resonance imaging (MRI) machines unless they have a fiberoptic ICP device. As directed, disconnect all cables and patient monitoring devices from the probe before entering the MRI environment to avoid serious patient injury.41
  • A CT scan may be performed to confirm catheter placement.29
  • Probes may remain in place for 5 to 7 days. Check the manufacturer’s guidelines.1

Complications ⬆ ⬇

Complications

Possible complications include infection, cerebrospinal fluid leak, and cerebral bleeding.

Documentation ⬆ ⬇

Documentation

Document neurologic assessments; ICP; vital signs, including temperature; pulse oximetry; insertion site assessment findings; and medications administered. Also document the patient’s tolerance of the procedure, any unexpected complications or outcomes, your interventions, and the patient’s response to those interventions. Record PbtO2 readings at least every hour. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

References ⬆

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  2. The Joint Commission. (2021). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  3. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13

    .
  4. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.11. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  5. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.3. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  6. The Joint Commission. (2021). Standard UP.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
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    Accreditation requirements for acute care hospitals

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    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/

    https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
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    Accreditation requirements for acute care hospitals

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    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  16. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

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    .
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  18. The Joint Commission. (2021). Standard RI.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  19. The Joint Commission. (2021). Standard PC.02.01.21. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
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    Managing alarms in acute care across the life span-Electrocardiography and pulse oximetry

    . https://www.aacn.org/clinical-resources/practice-alerts/managing-alarms-in-acute-care-across-the-life-span (Level VII)
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    Medical device alarm safety in hospitals

    . https://www.jointcommission.org/assets/1/6/SEA_50_alarms_4_26_16.pdf (Level VII)
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    Standardizing use of physiological monitors and decreasing nuisance alarms

    . American Journal of Critical Care, 19, 28–37.
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    Nursing services. 42 C.F.R. § 482.23(c)

    .
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    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  28. DNV GL-Healthcare USA, Inc. (2020). MM.1.SR.3. NIAHO® ­accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
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    AANN clinical practice guideline series

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    Accreditation requirements for acute care hospitals

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    Preventing transmission of infectious agents in healthcare settings

    . https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
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    Accreditation requirements for acute care hospitals

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    .
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    Accreditation requirements for acute care hospitals

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  40. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
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