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Bird JD, MacLeod DB, Griesdale DE, Sekhon MS, Hoiland RL. Shining a light on cerebral autoregulation: Are we anywhere near the truth? J Cereb Blood Flow Metab 2024; 44:1057-1060. [PMID: 38603610 DOI: 10.1177/0271678x241245488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
The near-infrared spectroscopy (NIRS)-derived cerebral oximetry index (COx) has become popularized for non-invasive neuromonitoring of cerebrovascular function in post-cardiac arrest patients with hypoxic-ischemic brain injury (HIBI). We provide commentary on the physiologic underpinnings and assumptions of NIRS and the COx, potential confounds in the context of HIBI, and the implications for the assessment of cerebral autoregulation.
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Affiliation(s)
- Jordan D Bird
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - David B MacLeod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada
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2
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Erklauer JC, Lai YC. The State of the Field of Pediatric Multimodality Neuromonitoring. Neurocrit Care 2023:10.1007/s12028-023-01858-3. [PMID: 37864125 DOI: 10.1007/s12028-023-01858-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND The use of multimodal neuromonitoring in pediatrics is in its infancy relative to adult neurocritical care. Multimodal neuromonitoring encompasses the amalgamation of information from multiple individual neuromonitoring devices to gain a more comprehensive understanding of the condition of the brain. It allows for adaptation to the changing state of the brain throughout various stages of injury with potential to individualize and optimize therapies. METHODS Here we provide an overview of multimodal neuromonitoring in pediatric neurocritical care and its potential application in the future. RESULTS Multimodal neuromonitoring devices are key to the process of multimodal neuromonitoring, allowing for visualization of data trends over time and ideally improving the ability of clinicians to identify patterns and find meaning in the immense volume of data now encountered in the care of critically ill patients at the bedside. Clinical use in pediatrics requires more study to determine best practices and impact on patient outcomes. Potential uses include guidance for targets of physiological parameters in the setting of acute brain injury, neuroprotection for patients at high risk for brain injury, and neuroprognostication. Implementing multimodal neuromonitoring in pediatric patients involves interprofessional collaboration with the development of a simultaneous comprehensive program to support the use of multimodal neuromonitoring while maintaining the fundamental principles of the delivery of neurocritical care at the bedside. CONCLUSIONS The possible benefits of multimodal neuromonitoring are immense and have great potential to advance the field of pediatric neurocritical care and the health of critically ill children.
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Affiliation(s)
- Jennifer C Erklauer
- Divisions of Critical Care Medicine and Pediatric Neurology and Developmental Neurosciences, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
| | - Yi-Chen Lai
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Hoiland RL, Robba C, Menon DK, Citerio G, Sandroni C, Sekhon MS. Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest. Intensive Care Med 2023; 49:1062-1078. [PMID: 37507572 PMCID: PMC10499700 DOI: 10.1007/s00134-023-07165-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
The cerebral oxygen cascade includes three key stages: (a) convective oxygen delivery representing the bulk flow of oxygen to the cerebral vascular bed; (b) diffusion of oxygen from the blood into brain tissue; and (c) cellular utilisation of oxygen for aerobic metabolism. All three stages may become dysfunctional after resuscitation from cardiac arrest and contribute to hypoxic-ischaemic brain injury (HIBI). Improving convective cerebral oxygen delivery by optimising cerebral blood flow has been widely investigated as a strategy to mitigate HIBI. However, clinical trials aimed at optimising convective oxygen delivery have yielded neutral results. Advances in the understanding of HIBI pathophysiology suggest that impairments in the stages of the oxygen cascade pertaining to oxygen diffusion and cellular utilisation of oxygen should also be considered in identifying therapeutic strategies for the clinical management of HIBI patients. Culprit mechanisms for these impairments may include a widening of the diffusion barrier due to peri-vascular oedema and mitochondrial dysfunction. An integrated approach encompassing both intra-parenchymal and non-invasive neuromonitoring techniques may aid in detecting pathophysiologic changes in the oxygen cascade and enable patient-specific management aimed at reducing the severity of HIBI.
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Affiliation(s)
- Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada.
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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Mølstrøm S, Nielsen TH, Nordstrøm CH, Forsse A, Møller S, Venø S, Mamaev D, Tencer T, Theódórsdóttir Á, Krøigård T, Møller J, Hassager C, Kjærgaard J, Schmidt H, Toft P. A randomized, double-blind trial comparing the effect of two blood pressure targets on global brain metabolism after out-of-hospital cardiac arrest. Crit Care 2023; 27:73. [PMID: 36823636 PMCID: PMC9951410 DOI: 10.1186/s13054-023-04376-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE This study aimed to assess the effect of different blood pressure levels on global cerebral metabolism in comatose patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS In a double-blinded trial, we randomly assigned 60 comatose patients following OHCA to low (63 mmHg) or high (77 mmHg) mean arterial blood pressure (MAP). The trial was a sub-study in the Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial (BOX). Global cerebral metabolism utilizing jugular bulb microdialysis (JBM) and cerebral oxygenation (rSO2) was monitored continuously for 96 h. The lactate-to-pyruvate (LP) ratio is a marker of cellular redox status and increases during deficient oxygen delivery (ischemia, hypoxia) and mitochondrial dysfunction. The primary outcome was to compare time-averaged means of cerebral energy metabolites between MAP groups during post-resuscitation care. Secondary outcomes included metabolic patterns of cerebral ischemia, rSO2, plasma neuron-specific enolase level at 48 h and neurological outcome at hospital discharge (cerebral performance category). RESULTS We found a clear separation in MAP between the groups (15 mmHg, p < 0.001). Cerebral biochemical variables were not significantly different between MAP groups (LPR low MAP 19 (16-31) vs. high MAP 23 (16-33), p = 0.64). However, the LP ratio remained high (> 16) in both groups during the first 30 h. During the first 24 h, cerebral lactate > 2.5 mM, pyruvate levels > 110 µM, LP ratio > 30, and glycerol > 260 µM were highly predictive for poor neurological outcome and death with AUC 0.80. The median (IQR) rSO2 during the first 48 h was 69.5% (62.0-75.0%) in the low MAP group and 69.0% (61.3-75.5%) in the high MAP group, p = 0.16. CONCLUSIONS Among comatose patients resuscitated from OHCA, targeting a higher MAP 180 min after ROSC did not significantly improve cerebral energy metabolism within 96 h of post-resuscitation care. Patients with a poor clinical outcome exhibited significantly worse biochemical patterns, probably illustrating that insufficient tissue oxygenation and recirculation during the initial hours after ROSC were essential factors determining neurological outcome.
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Affiliation(s)
- Simon Mølstrøm
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense, Denmark.
| | - Troels Halfeld Nielsen
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Carl-Henrik Nordstrøm
- grid.7143.10000 0004 0512 5013Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | - Axel Forsse
- grid.4973.90000 0004 0646 7373Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren Møller
- grid.7143.10000 0004 0512 5013OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Venø
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Dmitry Mamaev
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Tomas Tencer
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Ásta Theódórsdóttir
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- grid.7143.10000 0004 0512 5013Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Jacob Møller
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark ,grid.7143.10000 0004 0512 5013Department of Cardiology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Medicine, University of Southern, Odense, Denmark
| | - Christian Hassager
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjærgaard
- grid.4973.90000 0004 0646 7373The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Schmidt
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Palle Toft
- grid.7143.10000 0004 0512 5013Department of Anesthesiology and Intensive Care, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
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Carr JM, Ainslie PN, MacLeod DB, Tremblay JC, Nowak-Flück D, Howe CA, Stembridge M, Patrician A, Coombs GB, Stacey BS, Bailey DM, Green DJ, Hoiland RL. Cerebral O 2 and CO 2 transport in isovolumic haemodilution: Compensation of cerebral delivery of O 2 and maintenance of cerebrovascular reactivity to CO 2. J Cereb Blood Flow Metab 2023; 43:99-114. [PMID: 36131560 PMCID: PMC9875354 DOI: 10.1177/0271678x221119442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study investigated the influence of acute reductions in arterial O2 content (CaO2) via isovolumic haemodilution on global cerebral blood flow (gCBF) and cerebrovascular CO2 reactivity (CVR) in 11 healthy males (age; 28 ± 7 years: body mass index; 23 ± 2 kg/m2). Radial artery and internal jugular vein catheters provided measurement of blood pressure and gases, quantification of cerebral metabolism, cerebral CO2 washout, and trans-cerebral nitrite exchange (ozone based chemiluminescence). Prior to and following haemodilution, the partial pressure of arterial CO2 (PaCO2) was elevated with dynamic end-tidal forcing while gCBF was measured with duplex ultrasound. CVR was determined as the slope of the gCBF response and PaCO2. Replacement of ∼20% of blood volume with an equal volume of 5% human serum albumin (Alburex® 5%) reduced haemoglobin (13.8 ± 0.8 vs. 11.3 ± 0.6 g/dL; P < 0.001) and CaO2 (18.9 ± 1.0 vs 15.0 ± 0.8 mL/dL P < 0.001), elevated gCBF (+18 ± 11%; P = 0.002), preserved cerebral oxygen delivery (P = 0.49), and elevated CO2 washout (+11%; P = 0.01). The net cerebral uptake of nitrite (11.6 ± 14.0 nmol/min; P = 0.027) at baseline was abolished following haemodilution (-3.6 ± 17.9 nmol/min; P = 0.54), perhaps underpinning the conservation of CVR (61.7 ± 19.0 vs. 69.0 ± 19.2 mL/min/mmHg; P = 0.23). These findings demonstrate that the cerebrovascular responses to acute anaemia in healthy humans are sufficient to support the maintenance of CVR.
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Affiliation(s)
- Jay Mjr Carr
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7
| | - David B MacLeod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Joshua C Tremblay
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7
| | - Daniela Nowak-Flück
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7
| | - Connor A Howe
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7
| | - Mike Stembridge
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Alexander Patrician
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7
| | - Geoff B Coombs
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7.,School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Daniel J Green
- School of Human Sciences (Exercise and Sport Sciences), The University of Western Australia, Nedlands, Western Australia
| | - Ryan L Hoiland
- Centre for Heart, Lung and Vascular Health, University of British Columbia - Okanagan Campus, School of Health and Exercise Sciences, Kelowna, B.C., Canada, V1V 1V7.,Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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8
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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9
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Kirschen MP, Majmudar T, Diaz-Arrastia R, Berg R, Abella BS, Topjian A, Balu R. Deviations from PRx-derived optimal blood pressure are associated with mortality after cardiac arrest. Resuscitation 2022; 175:81-87. [PMID: 35276311 PMCID: PMC9135307 DOI: 10.1016/j.resuscitation.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 01/18/2023]
Abstract
AIM Pressure reactivity index (PRx) provides a surrogate measurement of cerebrovascular autoregulation (CAR). We determined whether deviations from PRx-derived optimal mean arterial pressure (MAPopt) were associated with in-hospital mortality after adult cardiac arrest. METHODS Retrospective analysis of post-cardiac arrest patients who had continuously recorded intracranial pressure (ICP) and MAP. PRx was calculated as a moving, linear correlation between ICP and MAP. Impaired CAR was defined as PRx ≥ 0.3. MAPopt was calculated using a multi-window weighted algorithm. The burdens of MAP < 5 mmHg below MAPopt (MAPopt-5) and > 5 mmHg above MAPopt (MAPopt + 5) were calculated by integrating the area between MAP and MAPopt-5 or MAPopt + 5 curves, respectively. Univariate logistic regression tested the association between burden of MAP < MAPopt-5 and outcome. RESULTS Twenty-two patients were analyzed. Thirteen (59%) patients died before hospital discharge. Time (median [IQR]) between ROSC and monitoring initiation was 16 [14, 21] hours and duration of monitoring was 35 [22, 48] hours; neither differed between survivors and non-survivors. Median MAPopt was 89 [85, 97] mmHg and did not differ between survivors and non-survivors (89 [83, 94] vs. 91 [85, 105] mmHg, p = 0.64). Burden of MAP < MAPopt-5 was greater for non-survivors compared to survivors (OR 3.6 [95% CI 1.2-15.6]). Range of intact CAR (upper-lower limit) was narrower for non-survivors when compared to survivors (5 [0, 22] vs. 24 [7, 36] mmHg, p = 0.03). CONCLUSION A greater burden of MAP below PRx-derived MAPopt-5 was associated with mortality after cardiac arrest. Non-survivors had a narrower range of intact CAR than survivors.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States.
| | | | | | - Robert Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Ramani Balu
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
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10
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Individualized cerebral perfusion pressure in acute neurological injury: are we ready for clinical use? Curr Opin Crit Care 2022; 28:123-129. [PMID: 35058408 DOI: 10.1097/mcc.0000000000000919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Individualizing cerebral perfusion pressure based on cerebrovascular autoregulation assessment is a promising concept for neurological injuries where autoregulation is typically impaired. The purpose of this review is to describe the status quo of autoregulation-guided protocols and discuss steps towards clinical use. RECENT FINDINGS Retrospective studies have indicated an association of impaired autoregulation and poor clinical outcome in traumatic brain injury (TBI), hypoxic-ischemic brain injury (HIBI) and aneurysmal subarachnoid hemorrhage (aSAH). The feasibility and safety to target a cerebral perfusion pressure optimal for cerebral autoregulation (CPPopt) after TBI was recently assessed by the COGITATE trial. Similarly, the feasibility to calculate a MAP target (MAPopt) based on near-infrared spectroscopy was demonstrated for HIBI. Failure to meet CPPopt is associated with the occurrence of delayed cerebral ischemia in aSAH but interventional trials in this population are lacking. No level I evidence is available on potential effects of autoregulation-guided protocols on clinical outcomes. SUMMARY The effect of autoregulation-guided management on patient outcomes must still be demonstrated in prospective, randomized, controlled trials. Selection of disease-specific protocols and endpoints may serve to evaluate the overall benefit from such approaches.
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11
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Deviations from NIRS-derived optimal blood pressure are associated with worse outcomes after pediatric cardiac arrest. Resuscitation 2021; 168:110-118. [PMID: 34600027 DOI: 10.1016/j.resuscitation.2021.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
AIM Evaluate cerebrovascular autoregulation (CAR) using near-infrared spectroscopy (NIRS) after pediatric cardiac arrest and determine if deviations from CAR-derived optimal mean arterial pressure (MAPopt) are associated with outcomes. METHODS CAR was quantified by a moving, linear correlation between time-synchronized mean arterial pressure (MAP) and regional cerebral oxygenation, called cerebral oximetry index (COx). MAPopt was calculated using a multi-window weighted algorithm. We calculated burden (magnitude and duration) of MAP less than 5 mmHg below MAPopt (MAPopt - 5), as the area between MAP and MAPopt - 5 curves using numerical integration and normalized as percentage of monitoring duration. Unfavorable outcome was defined as death or pediatric cerebral performance category (PCPC) at hospital discharge ≥3 with ≥1 change from baseline. Univariate logistic regression tested association between burden of MAP less than MAPopt - 5 and outcome. RESULTS Thirty-four children (median age 2.9 [IQR 1.5,13.4] years) were evaluated. Median COx in the first 24 h post-cardiac arrest was 0.06 [0,0.20]; patients spent 27% [19,43] of monitored time with COx ≥ 0.3. Patients with an unfavorable outcome (n = 24) had a greater difference between MAP and MAPopt - 5 (13 [11,19] vs. 9 [8,10] mmHg, p = 0.01) and spent more time with MAP below MAPopt - 5 (38% [26,61] vs. 24% [14,28], p = 0.03). Patients with unfavorable outcome had a higher burden of MAP less than MAPopt - 5 than patients with favorable outcome in the first 24 h post-arrest (187 [107,316] vs. 62 [43,102] mmHg × Min/Hr; OR 4.93 [95% CI 1.16-51.78]). CONCLUSIONS Greater burden of MAP below NIRS-derived MAPopt - 5 during the first 24 h after cardiac arrest was associated with unfavorable outcomes.
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12
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Laurikkala J, Aneman A, Peng A, Reinikainen M, Pham P, Jakkula P, Hästbacka J, Wilkman E, Loisa P, Toppila J, Birkelund T, Blennow K, Zetterberg H, Skrifvars MB. Association of deranged cerebrovascular reactivity with brain injury following cardiac arrest: a post-hoc analysis of the COMACARE trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:350. [PMID: 34583763 PMCID: PMC8477475 DOI: 10.1186/s13054-021-03764-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/09/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Impaired cerebrovascular reactivity (CVR) is one feature of post cardiac arrest encephalopathy. We studied the incidence and features of CVR by near infrared spectroscopy (NIRS) and associations with outcome and biomarkers of brain injury. METHODS A post-hoc analysis of 120 comatose OHCA patients continuously monitored with NIRS and randomised to low- or high-normal oxygen, carbon dioxide and mean arterial blood pressure (MAP) targets for 48 h. The tissue oximetry index (TOx) generated by the moving correlation coefficient between cerebral tissue oxygenation measured by NIRS and MAP was used as a dynamic index of CVR with TOx > 0 indicating impaired reactivity and TOx > 0.3 used to delineate the lower and upper MAP bounds for disrupted CVR. TOx was analysed in the 0-12, 12-24, 24-48 h time-periods and integrated over 0-48 h. The primary outcome was the association between TOx and six-month functional outcome dichotomised by the cerebral performance category (CPC1-2 good vs. 3-5 poor). Secondary outcomes included associations with MAP bounds for CVR and biomarkers of brain injury. RESULTS In 108 patients with sufficient data to calculate TOx, 76 patients (70%) had impaired CVR and among these, chronic hypertension was more common (58% vs. 31%, p = 0.002). Integrated TOx for 0-48 h was higher in patients with poor outcome than in patients with good outcome (0.89 95% CI [- 1.17 to 2.94] vs. - 2.71 95% CI [- 4.16 to - 1.26], p = 0.05). Patients with poor outcomes had a decreased upper MAP bound of CVR over time (p = 0.001), including the high-normal oxygen (p = 0.002), carbon dioxide (p = 0.012) and MAP (p = 0.001) groups. The MAP range of maintained CVR was narrower in all time intervals and intervention groups (p < 0.05). NfL concentrations were higher in patients with impaired CVR compared to those with intact CVR (43 IQR [15-650] vs 20 IQR [13-199] pg/ml, p = 0.042). CONCLUSION Impaired CVR over 48 h was more common in patients with chronic hypertension and associated with poor outcome. Decreased upper MAP bound and a narrower MAP range for maintained CVR were associated with poor outcome and more severe brain injury assessed with NfL. Trial registration ClinicalTrials.gov, NCT02698917 .
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Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland.
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Alexander Peng
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Paul Pham
- Dept of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland
| | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | - Jussi Toppila
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,DUK Dementia Research Institute at UCL, London, UK.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Skrifvars MB, Sekhon M, Åneman EA. Monitoring and modifying brain oxygenation in patients at risk of hypoxic ischaemic brain injury after cardiac arrest. Crit Care 2021; 25:312. [PMID: 34461973 PMCID: PMC8406909 DOI: 10.1186/s13054-021-03678-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Markus Benedikt Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Erik Anders Åneman
- Southwestern Clinical School, University of New South Wales, Sydney, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- College of Health and Medicine, Australian National University, Canberra, NSW, Australia
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, NSW, Australia
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14
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Kwon WY, Jung YS, Suh GJ, Kim T, Kwak H, Kim T, Kim JY, Lee MS, Kim KS, Shin J, Lee HJ, You KM. Regional cerebral oxygen saturation in cardiac arrest survivors undergoing targeted temperature management 36℃ versus 33℃: A randomized clinical trial. Resuscitation 2021; 167:362-371. [PMID: 34331985 DOI: 10.1016/j.resuscitation.2021.07.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/16/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022]
Abstract
AIM of study To investigate whether regional cerebral oxygen saturation (rSO2) differs in out-of-hospital cardiac arrest (OHCA) survivors undergoing targeted temperature management (TTM) 36℃ versus 33℃. METHODS A randomized clinical trial was conducted at intensive care units in two referral hospitals. Fifty-seven comatose OHCA survivors were randomized into either a 36℃ or 33℃ group. Patients were cooled and maintained at an oesophageal temperature of either 36℃ or 33℃ for 24 hours, rewarmed at a rate of 0.25℃/hour, and maintained at < 37.5℃ until 72 hours. During 72 hours of TTM, rSO2 was continuously monitored on the left forehead using near-infrared spectroscopy (INVOSTM 5100C). The rSO2 level at 72 hours was compared between the two groups. Next, serial rSO2 levels for 72 hours were compared using mixed effects regression. The association between rSO2 levels and 6-month neurological outcomes was also evaluated. RESULTS There were no significant differences in the rSO2 level at 72 hours between the 36℃ and 33℃ groups (p = 0.372). Furthermore, serial rSO2 levels for 72 hours of TTM were not different between the two groups (p = 0.733). However, low rSO2 levels, particularly at 24 hours of TTM, were significantly associated with poor 6-month neurological outcomes (odds ratio = 0.899, 95% confidence interval: 0.831 - 0.974). The area under the receiver operating characteristic curve of the rSO2 level at 24 hours for poor neurological outcomes was 0.800. CONCLUSIONS Regardless of target temperatures, low rSO2 levels during TTM were significantly associated with poor 6-month neurological outcomes in OHCA survivors.
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Affiliation(s)
- Woon Yong Kwon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Yoon Sun Jung
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Taekyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Hyeongkyu Kwak
- Department of Emergency Medicine, Uijeongbu Eulji University Hospital/Eulji University School of Medicine, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Taekwon Kim
- Department of Emergency Medicine, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
| | - Jeong Yeon Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Min Sung Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Kyung Su Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
| | - Kyung Min You
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea
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Badenes R, Bogossian EG, Chisbert V, Robba C, Oddo M, Taccone FS, Matta BF. The role of non-invasive brain oximetry in adult critically ill patients without primary brain injury. Minerva Anestesiol 2021; 87:1226-1238. [PMID: 33938677 DOI: 10.23736/s0375-9393.21.15333-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A primary objective in intensive care and perioperative settings is to promote an adequate supply and delivery of oxygen to tissues and organs, particularly to the brain. Cerebral near infrared spectroscopy (NIRS) is a non-invasive, continuous monitoring technique, that can be used to assess cerebral oxygenation. Using NIRS to monitor cerebral oximetry is not new, and has been in widespread use in neonates and cardiac surgery for decades. In addition, it has become common to see NIRS being used in adult and pediatric cardiac surgery, acute neurological diseases, neurosurgical procedures, vascular surgery, severe trauma and other acute medical diseases. Furthermore, recent evidence suggests a role for NIRS in the perioperative settings; detecting and preventing episodes of cerebral desaturation aiming to reduce the development of post-operative delirium. NIRS is not without its limitations; these include the risk of extra-cranial contamination, spatial limitations and skin blood flow/volume changes, as well being a measure of localized blood oxygenation underneath the sensor. However, NIRS is a non-invasive technique and can, therefore, be used in those patients without indications or justification for invasive brain monitoring; non-neurosurgical procedures such as liver transplantation, major orthopedic surgery and critically illness where the brain is at risk. The aim of this manuscript was to discuss the physical principles of NIRS and to report the current evidence regarding its use in critically ill patients without primary non-anoxic brain injury.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain - .,Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain - .,INCLIVA Health Research Institute, Valencia, Spain -
| | - Elisa G Bogossian
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Vicente Chisbert
- INCLIVA Health Research Institute, Valencia, Spain.,Escuela de Doctorado, Universidad Católica de Valencia, Valencia, Spain
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCSS S. Martino Hospital, Genoa, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Basil F Matta
- Trauma and NeuroCritical Care Unit, Cambridge University Hospital, Cambridge, UK
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16
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Neuromonitoring After Cardiac Arrest: Can Twenty-First Century Medicine Personalize Post Cardiac Arrest Care? Neurol Clin 2021; 39:273-292. [PMID: 33896519 DOI: 10.1016/j.ncl.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac arrest survivors comprise a heterogeneous population, in which the etiology of arrest, systemic and neurologic comorbidities, and sequelae of post-cardiac arrest syndrome influence the severity of secondary brain injury. The degree of secondary neurologic injury can be modifiable and is influenced by factors that alter cerebral physiology. Neuromonitoring techniques provide tools for evaluating the evolution of physiologic variables over time. This article reviews the pathophysiology of hypoxic-ischemic brain injury, provides an overview of the neuromonitoring tools available to identify risk profiles for secondary brain injury, and highlights the importance of an individualized approach to post cardiac arrest care.
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17
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Goal-Directed Care Using Invasive Neuromonitoring Versus Standard of Care After Cardiac Arrest: A Matched Cohort Study. Crit Care Med 2021; 49:1333-1346. [PMID: 33711002 DOI: 10.1097/ccm.0000000000004945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Following return of spontaneous circulation after cardiac arrest, hypoxic ischemic brain injury is the primary cause of mortality and disability. Goal-directed care using invasive multimodal neuromonitoring has emerged as a possible resuscitation strategy. We evaluated whether goal-directed care was associated with improved neurologic outcome in hypoxic ischemic brain injury patients after cardiac arrest. DESIGN Retrospective, single-center, matched observational cohort study. SETTING Quaternary academic medical center. PATIENTS Adult patients admitted to the ICU following return of spontaneous circulation postcardiac arrest with clinical evidence of hypoxic ischemic brain injury defined as greater than or equal to 10 minutes of cardiac arrest with an unconfounded postresuscitation Glasgow Coma Scale of less than or equal to 8. INTERVENTIONS We compared patients who underwent goal-directed care using invasive neuromonitoring with those treated with standard of care (using both total and matched groups). MEASUREMENTS AND MAIN RESULTS Goal-directed care patients were matched 1:1 to standard of care patients using propensity scores and exact matching. The primary outcome was a 6-month favorable neurologic outcome (Cerebral Performance Category of 1 or 2). We included 65 patients, of whom 21 received goal-directed care and 44 patients received standard of care. The median age was 50 (interquartile range, 35-61), 48 (74%) were male, and seven (11%) had shockable rhythms. Favorable neurologic outcome at 6 months was significantly greater in the goal-directed care group (n = 9/21 [43%]) compared with the matched (n = 2/21 [10%], p = 0.016) and total (n = 8/44 [18%], p = 0.034) standard of care groups. Goal-directed care group patients had higher mean arterial pressure (p < 0.001 vs total; p = 0.0060 vs matched) and lower temperature (p = 0.007 vs total; p = 0.041 vs matched). CONCLUSIONS In this preliminary study of patients with hypoxic ischemic brain injury postcardiac arrest, goal-directed care guided by invasive neuromonitoring was associated with a 6-month favorable neurologic outcome (Cerebral Performance Category 1 or 2) versus standard of care. Significant work is required to confirm this finding in a prospectively designed study.
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18
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Kirschen MP, Morgan RW, Majmudar T, Landis WP, Ko T, Balu R, Balasubramanian S, Topjian A, Sutton RM, Berg RA, Kilbaugh TJ. The association between early impairment in cerebral autoregulation and outcome in a pediatric swine model of cardiac arrest. Resusc Plus 2020; 4:100051. [PMID: 34223325 PMCID: PMC8244245 DOI: 10.1016/j.resplu.2020.100051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/03/2020] [Accepted: 11/08/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS Evaluate cerebral autoregulation (CAR) by intracranial pressure reactivity index (PRx) and cerebral blood flow reactivity index (CBFx) during the first four hours following return of spontaneous circulation (ROSC) in a porcine model of pediatric cardiac arrest. Determine whether impaired CAR is associated with neurologic outcome. METHODS Four-week-old swine underwent seven minutes of asphyxia followed by ventricular fibrillation induction and hemodynamic-directed CPR. Those achieving ROSC had arterial blood pressure, intracranial pressure (ICP), and microvascular cerebral blood flow (CBF) monitored for 4 h. Animals were assigned an 8 -h post-ROSC swine cerebral performance category score (1 = normal; 2-4=abnormal neurologic function). In this secondary analytic study, we calculated PRx and CBFx using a continuous, moving correlation coefficient between mean arterial pressure (MAP) and ICP, and between MAP and CBF, respectively. Burden of impaired CAR was the area under the PRx or CBFx curve using a threshold of 0.3 and normalized as percentage of monitoring duration. RESULTS Among 23 animals, median PRx was 0.14 [0.06,0.25] and CBFx was 0.36 [0.05,0.44]. Median burden of impaired CAR was 21% [18,27] with PRx and 30% [17,40] with CBFx. Neurologically abnormal animals (n = 10) did not differ from normal animals (n = 13) in post-ROSC MAP (63 vs. 61 mmHg, p = 0.74), ICP (15 vs. 14 mmHg, p = 0.78) or CBF (274 vs. 397 Perfusion Units, p = 0.12). CBFx burden was greater among abnormal than normal animals (45% vs. 24%, p = 0.001), but PRx burden was not (25% vs. 20%, p = 0.38). CONCLUSION CAR is impaired early after ROSC. A greater burden of CAR impairment measured by CBFx was associated with abnormal neurologic outcome.CHOP Institutional Animal Care and Use Committee protocol 19-001327.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, USA
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Tanmay Majmudar
- School of Biomedical Engineering, Science and Health Systems, Drexel University, USA
| | - William P. Landis
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Ramani Balu
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, USA
| | | | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, USA
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19
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Hoiland RL, Griesdale DE, Sekhon MS. Assessing autoregulation using near infrared spectroscopy: more questions than answers. Resuscitation 2020; 156:280-281. [PMID: 32858154 DOI: 10.1016/j.resuscitation.2020.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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20
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Eertmans W, Salcido D, Genbrugge C. Regional cerebral saturation in post-cardiac arrest patients is doomed… or is it just a near death experience? Resuscitation 2020; 154:117-118. [PMID: 32673733 DOI: 10.1016/j.resuscitation.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Ward Eertmans
- Departement of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - David Salcido
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cornelia Genbrugge
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium; Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Belgium.
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21
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Skrifvars MB, Åneman A. Near-infrared spectroscopy “under pressure” as a post-cardiac arrest monitoring technique of cerebral autoregulation. Resuscitation 2020; 152:203-204. [DOI: 10.1016/j.resuscitation.2020.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/16/2022]
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