Outcome after traumatic brain injury (TBI) depends on the extent of primary cell death and on the development of secondary brain injury. The general aim of this thesis was to find strategies and quality systems to minimize the extent of secondary insults in neurointensive care (NIC). An established standardized management protocol system, multimodality monitoring and computerized data collection, and analysis systems were used. The Uppsala TBI register was established for regular monitoring of NIC quality indexes. For 2008-2010 the proportion of patients improving during NIC was 60-80%, whereas 10% deteriorated. The percentage of ‘talk and die’ cases was < 1%. The occurrences of secondary insults were less than 5% of good monitoring time (GMT) for intracranial pressure (ICP) > 25 mmHg, cerebral perfusion pressure (CPP) < 50 mmHg and systolic blood pressure < 100 mmHg. Favorable outcome was achieved by 64% of adults. Nurse checklists of secondary insult occurrence were introduced. Evaluation of the use of nursing checklists showed that the nurses documented their assessments in 84-85% of the shifts and duration of monitoring time at insult level was significantly longer when secondary insults were reported regarding ICP, CPP and temperature. The use of nurse checklist was found to be feasible and accurate.  A clinical tool to avoid secondary insults related to nursing interventions was developed. Secondary brain insults occurred in about 10% of nursing interventions. There were substantial variations between patients. The risk ratios of developing an ICP insult were 4.7 when baseline ICP ≥ 15 mmHg, 2.9 when ICP amplitude ≥ 6 mmHg and 1.7 when pressure autoregulation ≥ 0.3. Hyperthermia, which is a known frequent secondary insult, was studied. Hyperthermia was most common on Day 7 after admission and 90% of the TBI patients had hyperthermia during the first 10 days at the NIC unit. The effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism and BtipO2) were small but individual differences were observed. Hyperthermia increased ICP slightly more when temperature increased in the groups with low compliance and impaired pressure autoregulation. Ischemic pattern was never observed in the microdialysis samples. The treatment of hyperthermia may be individualized and guided by multimodality monitoring.

Simple Summary Good oxygenation of both bowel ends is an important prerequisite to promote anastomotic healing after colorectal resections. Bowel oxygenation is usually assessed clinically. Hyperspectral imaging is a contactless and contrast-free tool that allows quantifying tissue oxygen intraoperatively. In this study, the results of 105 colorectal resections with hyperspectral imaging are reported. Abstract Background: A perfusion deficit is a well-defined and intraoperatively influenceable cause of anastomotic leak (AL). Current intraoperative perfusion assessment methods do not provide objective and quantitative results. In this study, the ability of hyperspectral imaging (HSI) to quantify tissue oxygenation intraoperatively was assessed. Methods: 115 patients undergoing colorectal resections were included in the final analysis. Before anastomotic formation, the bowel was extracted and the resection line was outlined and imaged using a compact HSI camera, in order to provide instantaneously quantitative perfusion assessment. Results: In 105 patients, a clear demarcation line was visible with HSI one minute after marginal artery transection, reaching a plateau after 3 min. In 58 (55.2%) patients, the clinically determined transection line matched with HSI. In 23 (21.9%) patients, the clinically established resection margin was entirely within the less perfused area. In 24 patients (22.8%), the HSI transection line had an irregular course and crossed the clinically established resection line. In four cases, HSI disclosed a clinically undetected lesion of the marginal artery. Conclusions: Intraoperative HSI is safe, well reproducible, and does not disrupt the surgical workflow. It also quantifies bowel surface perfusion. HSI might become an intraoperative guidance tool, potentially preventing postoperative complications.

AbstractIn the field of Biomedical Optics measurement of tissue optical properties, like absorption, scattering, and reduced scattering coefficient, has gained importance for therapeutic and diagnostic applications. Accuracy in determining the optical properties is of vital importance to quantitatively determine chromophores in tissue.There are different techniques used to quantify tissue chromophores. Reflectance spectroscopy is one of the most common methods to rapidly and accurately characterize the blood amount and oxygen saturation in the microcirculation. With a hyper spectral imaging (HSI) device it is possible to capture images with spectral information that depends both on tissue absorption and scattering. To analyze this data software that accounts for both absorption and scattering event needs to be developed.In this thesis work an HSI algorithm, capable of assessing tissue oxygenation while accounting for both tissue absorption and scattering, is developed. The complete imaging system comprises: a light source, a liquid crystal tunable filter (LCTF), a camera lens, a CCD camera, control units and power supply for light source and filter, and a computer.This work also presents a Graphic processing Unit (GPU) implementation of the developed HSI algorithm, which is found computationally demanding. It is found that the GPU implementation outperforms the Matlab “lsqnonneg” function by the order of 5-7X.At the end, the HSI system and the developed algorithm is evaluated in two experiments. In the first experiment the concentration of chromophores is assessed while occluding the finger tip. In the second experiment the skin is provoked by UV light while checking for Erythema development by analyzing the oxyhemoglobin image at different point of time. In this experiment the melanin concentration change is also checked at different point of time from exposure.It is found that the result matches the theory in the time dependent change of oxyhemoglobin and deoxyhemoglobin. However, the result of melanin does not correspond to the theoretically expected result.

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