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Alhumaid S, Alnaim AA, Al Ghamdi MA, Alahmari AA, Alabdulqader M, Al HajjiMohammed SM, Alalwan QM, Al Dossary N, Alghazal HA, Al Hassan MH, Almaani KM, Alhassan FH, Almuhanna MS, Alshakhes AS, BuMozah AS, Al-Alawi AS, Almousa FM, Alalawi HS, Al Matared SM, Alanazi FA, Aldera AH, AlBesher MA, Almuhaisen RH, Busubaih JS, Alyasin AH, Al Majhad AA, Al Ithan IA, Alzuwaid AS, Albaqshi MA, Alhmeed N, Albaqshi YA, Al Alawi Z. International treatment outcomes of neonates on extracorporeal membrane oxygenation (ECMO) with persistent pulmonary hypertension of the newborn (PPHN): a systematic review. J Cardiothorac Surg 2024; 19:493. [PMID: 39182148 PMCID: PMC11344431 DOI: 10.1186/s13019-024-03011-3] [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: 04/07/2024] [Accepted: 08/13/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND PPHN is a common cause of neonatal respiratory failure and is still a serious condition and associated with high mortality. OBJECTIVES To compare the demographic variables, clinical characteristics, and treatment outcomes in neonates with PHHN who underwent ECMO and survived compared to neonates with PHHN who underwent ECMO and died. METHODS We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and searched ProQuest, Medline, Embase, PubMed, CINAHL, Wiley online library, Scopus and Nature for studies on the development of PPHN in neonates who underwent ECMO, published from January 1, 2010 to May 31, 2023, with English language restriction. RESULTS Of the 5689 papers that were identified, 134 articles were included in the systematic review. Studies involving 1814 neonates with PPHN who were placed on ECMO were analyzed (1218 survived and 594 died). Neonates in the PPHN group who died had lower proportion of normal spontaneous vaginal delivery (6.4% vs 1.8%; p value > 0.05) and lower Apgar scores at 1 min and 5 min [i.e., low Apgar score: 1.5% vs 0.5%, moderately abnormal Apgar score: 10.3% vs 1.2% and reassuring Apgar score: 4% vs 2.3%; p value = 0.039] compared to those who survived. Neonates who had PPHN and died had higher proportion of medical comorbidities such as omphalocele (0.7% vs 4.7%), systemic hypotension (1% vs 2.5%), infection with Herpes simplex virus (0.4% vs 2.2%) or Bordetella pertussis (0.7% vs 2%); p = 0.042. Neonates with PPHN in the death group were more likely to present due to congenital diaphragmatic hernia (25.5% vs 47.3%), neonatal respiratory distress syndrome (4.2% vs 13.5%), meconium aspiration syndrome (8% vs 12.1%), pneumonia (1.6% vs 8.4%), sepsis (1.5% vs 8.2%) and alveolar capillary dysplasia with misalignment of pulmonary veins (0.1% vs 4.4%); p = 0.019. Neonates with PPHN who died needed a longer median time of mechanical ventilation (15 days, IQR 10 to 27 vs. 10 days, IQR 7 to 28; p = 0.024) and ECMO use (9.2 days, IQR 3.9 to 13.5 vs. 6 days, IQR 3 to 12.5; p = 0.033), and a shorter median duration of hospital stay (23 days, IQR 12.5 to 46 vs. 58.5 days, IQR 28.2 to 60.7; p = 0.000) compared to the neonates with PPHN who survived. ECMO-related complications such as chylothorax (1% vs 2.7%), intracranial bleeding (1.2% vs 1.7%) and catheter-related infections (0% vs 0.3%) were more frequent in the group of neonates with PPHN who died (p = 0.031). CONCLUSION ECMO in the neonates with PPHN who failed supportive cardiorespiratory care and conventional therapies has been successfully utilized with a neonatal survival rate of 67.1%. Mortality in neonates with PPHN who underwent ECMO was highest in cases born via the caesarean delivery mode or neonates who had lower Apgar scores at birth. Fatality rate in neonates with PPHN who underwent ECMO was the highest in patients with higher rate of specific medical comorbidities (omphalocele, systemic hypotension and infection with Herpes simplex virus or Bordetella pertussis) or cases who had PPHN due to higher rate of specific etiologies (congenital diaphragmatic hernia, neonatal respiratory distress syndrome and meconium aspiration syndrome). Neonates with PPHN who died may need a longer time of mechanical ventilation and ECMO use and a shorter duration of hospital stay; and may experience higher frequency of ECMO-related complications (chylothorax, intracranial bleeding and catheter-related infections) in comparison with the neonates with PPHN who survived.
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Affiliation(s)
- Saad Alhumaid
- School of Pharmacy, University of Tasmania, Hobart, 7000, Australia.
| | - Abdulrahman A Alnaim
- Department of Pediatrics, College of Medicine, King Faisal University, 31982, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Mohammed A Al Ghamdi
- Department of Pediatrics, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, 34212, Dammam, Saudi Arabia
| | - Abdulaziz A Alahmari
- Department of Pediatrics, King Fahad Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, 34212, Dammam, Saudi Arabia
| | - Muneera Alabdulqader
- Pediatric Nephrology Specialty, Pediatric Department, Medical College, King Faisal University, 31982, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Sarah Mahmoud Al HajjiMohammed
- Pharmacy Department, Prince Saud Bin Jalawi Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36424, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Qasim M Alalwan
- Pediatric Radiology Department, King Fahad Hofuf Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36441, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Nourah Al Dossary
- General Surgery Department, Alomran General Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36358, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Header A Alghazal
- Microbiology Laboratory, Prince Saud Bin Jalawi Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36424, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Mohammed H Al Hassan
- Administration of Nursing, Al-Ahsa Health Cluster, Al-Ahsa Health Cluster, Ministry of Health, 36421, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Khadeeja Mirza Almaani
- Alyahya Primary Health Centre, Primary Care Medicine, Al-Ahsa Health Cluster, Ministry of Health, 36341, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Fatimah Hejji Alhassan
- Alyahya Primary Health Centre, Primary Care Medicine, Al-Ahsa Health Cluster, Ministry of Health, 36341, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Mohammed S Almuhanna
- Department of Pharmacy, Maternity and Children Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36422, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Aqeel S Alshakhes
- Department of Psychiatry, Prince Saud Bin Jalawi Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36424, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Ahmed Salman BuMozah
- Administration of Dental Services, Al-Ahsa Health Cluster, Ministry of Health, 36421, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Ahmed S Al-Alawi
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, 36421, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Fawzi M Almousa
- Pharmacy Department, Al Jabr Hospital for Eye, Ear, Nose and Throat, Al-Ahsa Health Cluster, Ministry of Health, 36422, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Hassan S Alalawi
- Pharmacy Department, Imam Abdulrahman Alfaisal Hospital, C1 Riyadh Health Cluster, Ministry of Health, 14723, Riyadh, Saudi Arabia
| | - Saleh Mana Al Matared
- Department of Public Health, Kubash General Hospital, Ministry of Health, 66244, Najran, Saudi Arabia
| | | | - Ahmed H Aldera
- Pharmacy Department, Prince Saud Bin Jalawi Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36424, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Mustafa Ahmed AlBesher
- Regional Medical Supply, Al-Ahsa Health Cluster, Ministry of Health, 36361, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Ramzy Hasan Almuhaisen
- Quality Assurance and Patient Safety Administration, Directorate of Health Affairs, Ministry of Health, 36441, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Jawad S Busubaih
- Gastroenterology Department, King Fahad Hofuf Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36441, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Ali Hussain Alyasin
- Medical Store Department, Maternity and Children Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36422, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Abbas Ali Al Majhad
- Radiology Department, Prince Saud Bin Jalawi Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36424, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Ibtihal Abbas Al Ithan
- Renal Dialysis Department, King Fahad Hofuf Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36441, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Ahmed Saeed Alzuwaid
- Pharmacy Department, Aljafr General Hospital, Al-Ahsa Health Cluster, Ministry of Health, 7110, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Mohammed Ali Albaqshi
- Pharmacy Department, Aljafr General Hospital, Al-Ahsa Health Cluster, Ministry of Health, 7110, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Naif Alhmeed
- Administration of Supply and Shared Services, C1 Riyadh Health Cluster, Ministry of Health, 14723, Riyadh, Saudi Arabia
| | - Yasmine Ahmed Albaqshi
- Respiratory Therapy Department, Maternity and Children Hospital, Al-Ahsa Health Cluster, Ministry of Health, 36422, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Zainab Al Alawi
- Division of Allergy and Immunology, College of Medicine, King Faisal University, 31982, Al-Hofuf, Al-Ahsa, Saudi Arabia
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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Siddiqui K, Hafeez MU, Ahmad A, Kazmi SO, Chatterjee S, Bershad E, Hirzallah M, Rao C, Damani R. Multimodal Neurologic Monitoring in Patients Undergoing Extracorporeal Membrane Oxygenation. Cureus 2024; 16:e59476. [PMID: 38826870 PMCID: PMC11140437 DOI: 10.7759/cureus.59476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is associated with a high rate of neurologic complications. Multimodal neurologic monitoring (MNM) has the potential for early detection and intervention. We examined the safety and feasibility of noninvasive MNM during ECMO. We hypothesized that survivors and non-survivors would have meaningful differences in transcranial Doppler (TCD) sonography and electroencephalographic (EEG) characteristics, which we aimed to identify. We also investigated adverse neurologic events and attempted to identify differences in EEG and TCD characteristics among patients based on the type of ECMO and the occurrence of these events. Material and methods We performed an observational study on all patients undergoing ECMO at Baylor St. Luke's Medical Center's critical care unit in Houston, Texas, United States, from January 2017 to February 2019. All patients underwent a noninvasive MNM protocol. Results NM was completed in 75% of patients; all patients received at least one component of the monitoring protocol. No adverse events were noted, showing the feasibility and safety of the protocol. The 60.4% of patients who did not survive tended to be older, had lower ejection fractions, and had lower median right middle cerebral artery (MCA) pulsatility and resistivity indexes. Patients undergoing venoarterial (VA)-ECMO had lower median left and right MCA velocities and lower right Lindegaard ratios than patients who underwent venovenous-ECMO. In VA-ECMO patients, EEG less often showed sleep architecture, while other findings were similar between groups. Adverse neurologic events occurred in 24.7% of patients, all undergoing VA-ECMO. Acute ischemic stroke occurred in 22% of patients, intraparenchymal hemorrhage in 4.9%, hypoxic-ischemic encephalopathy in 3.7%, subarachnoid hemorrhage in 2.5%, and subdural hematoma in 1.2%. Conclusion Our results suggest that MNM is safe and feasible for patients undergoing ECMO. Certain EEG and TCD findings could aid in the early detection of neurologic deterioration. MNM may not just be used in monitoring patients undergoing ECMO but also in prognostication and aiding clinical decision-making.
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Affiliation(s)
| | | | - Ali Ahmad
- Neurology, Baylor College of Medicine, Houston, USA
| | - Syed O Kazmi
- Neurology, Salem Health Hospitals & Clinics, Salem, USA
| | | | - Eric Bershad
- Neurology, Baylor College of Medicine, Houston, USA
| | | | - Chethan Rao
- Neurocritical Care, Baylor College of Medicine, Houston, USA
| | - Rahul Damani
- Neurology, Baylor College of Medicine, Houston, USA
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Tabet M, Custer C, Khan IR, Sanford E, Sharma J, Choe R, Singh S, Sirsi D, Olson DM, Morriss MC, Raman L, Busch DR. Neuromonitoring of Pediatric and Adult Extracorporeal Membrane Oxygenation Patients: The Importance of Continuous Bedside Tools in Driving Neuroprotective Clinical Care. ASAIO J 2024; 70:167-176. [PMID: 38051987 DOI: 10.1097/mat.0000000000002107] [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: 12/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of temporary cardiopulmonary bypass for patients with acute respiratory or cardiac failure refractory to conventional therapy. Its usage has become increasingly widespread and while reported survival after ECMO has increased in the past 25 years, the incidence of neurological injury has not declined, leading to the pressing question of how to improve time-to-detection and diagnosis of neurological injury. The neurological status of patients on ECMO is clinically difficult to evaluate due to multiple factors including illness, sedation, and pharmacological paralysis. Thus, increasing attention has been focused on developing tools and techniques to measure and monitor the brain of ECMO patients to identify dynamic risk factors and monitor patients' neurophysiological state as a function in time. Such tools may guide neuroprotective interventions and thus prevent or mitigate brain injury. Current means to continuously monitor and prevent neurological injury in ECMO patients are rather limited; most techniques provide indirect or postinsult recognition of irreversible brain injury. This review will explore the indications, advantages, and disadvantages of standard-of-care, emerging, and investigational technologies for neurological monitoring on ECMO, focusing on bedside techniques that provide continuous assessment of neurological health.
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Affiliation(s)
- Margherita Tabet
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Chasity Custer
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Imad R Khan
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ethan Sanford
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Jayesh Sharma
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
| | - Regine Choe
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
- Department of Electrical and Computer Engineering, University of Rochester, Rochester, New York
| | - Sumit Singh
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Deepa Sirsi
- Division of Pediatric Neurology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - DaiWai M Olson
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Department of Pediatrics, The University of Texas Southwestern medical center
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, The University of Texas Southwestern medical center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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Burzyńska M, Uryga A, Kasprowicz M, Czosnyka M, Goździk W, Robba C. Cerebral Autoregulation, Cerebral Hemodynamics, and Injury Biomarkers, in Patients with COVID-19 Treated with Veno-Venous Extracorporeal Membrane Oxygenation. Neurocrit Care 2023; 39:425-435. [PMID: 36949359 PMCID: PMC10033181 DOI: 10.1007/s12028-023-01700-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/14/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND This study aimed to describe the cerebrovascular dynamics, in particular cerebral autoregulation (CA), and cerebral biomarkers as neuron-specific enolase (NSE) in patients with a diagnosis of coronavirus disease 2019 and acute respiratory distress syndrome as well as undergoing veno-venous extracorporeal membrane treatment. METHODS This was a single center, observational study conducted in the intensive care unit of the University Hospital in Wroclaw from October 2020 to February 2022. Transcranial Doppler recordings of the middle cerebral artery conducted for at least 20 min were performed. Cerebral autoregulation (CA) was estimated by using the mean velocity index (Mxa), calculated as the moving correlation coefficient between slow-wave oscillations in cerebral blood flow velocity and arterial blood pressure. Altered CA was defined as a positive Mxa. Blood samples for the measurement of NSE were obtained at the same time as transcranial Doppler measurements. RESULTS A total of 16 patients fulfilled the inclusion criteria and were enrolled in the study. The median age was 39 (34-56) years. Altered CA was found in 12 patients, and six out of seven patients who died had altered CA. A positive Mxa was a significant predictor of mortality, with a sensitivity of 85.7%. We found that three out of five patients with pathological changes in brain computed tomography and six out of ten patients with neurological complications had altered CA. NSE was a significant predictor of mortality (cutoff value: 28.9 µg/L); area under the curve = 0.83, p = 0.006), with a strong relationship between increased level of NSE and altered CA, χ2 = 6.24; p = 0.035; φ = 0.69. CONCLUSIONS Patients with coronavirus disease 2019-related acute respiratory distress syndrome, requiring veno-venous extracorporeal membrane treatment, are likely to have elevated NSE levels and altered CA. The CA was associated with NSE values in this group. This preliminary analysis suggests that advanced neuromonitoring and evaluation of biomarkers should be considered in this population.
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Affiliation(s)
- Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370, Wroclaw, Poland.
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wybrzeze Wyspianskiego 27, 50-370, Wroclaw, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - Waldemar Goździk
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Chiara Robba
- IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
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Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical Guidelines for Routine Neuromonitoring in Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:895-900. [PMID: 37603797 DOI: 10.1097/mat.0000000000001896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
DISCLAIMER These guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation (ECMO) are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO but these are not necessarily consensus recommendations. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Poornima Pandiyan
- From the Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Mirjana Cvetkovic
- Cardiac Critical Care Division, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebekah K H Shappley
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Swati A Karmakar
- Department of Pediatrics, Baylor College of Medicine, Neurology and Developmental Neuroscience Section, Texas Children's Hospital, Houston, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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Shah N, Li X, Shanmugham P, Fan E, Thiagarajan RR, Venkataraman R, Raman L. Early Changes in Arterial Partial Pressure of Carbon Dioxide and Blood Pressure After Starting Extracorporeal Membrane Oxygenation in Children: Extracorporeal Life Support Organization Database Study of Neurologic Complications. Pediatr Crit Care Med 2023; 24:541-550. [PMID: 36877009 DOI: 10.1097/pcc.0000000000003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Neurologic complications in pediatric patients supported by extracorporeal membrane oxygenation (ECMO) are common and lead to morbidity and mortality; however, few modifiable factors are known. DESIGN Retrospective study of the Extracorporeal Life Support Organization registry (2010-2019). SETTING Multicenter international database. PATIENTS Pediatric patients receiving ECMO (2010-2019) for all indications and any mode of support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We investigated if early relative change in Pa co2 or mean arterial blood pressure (MAP) soon after starting ECMO was associated with neurologic complications. The primary outcome of neurologic complications was defined as a report of seizures, central nervous system infarction or hemorrhage, or brain death. All-cause mortality (including brain death) was used as a secondary outcome.Out of 7,270 patients, 15.6% had neurologic complications. Neurologic complications increased when the relative Pa co2 decreased by greater than 50% (18.4%) or 30-50% (16.5%) versus those who had a minimal change (13.9%, p < 0.01 and p = 0.046). When the relative MAP increased greater than 50%, the rate of neurologic complications was 16.9% versus 13.1% those with minimal change ( p = 0.007). In a multivariable model adjusting for confounders, a relative decrease in Pa co2 greater than 30% was independently associated with greater odds of neurologic complication (odds ratio [OR], 1.25; 95% CI, 1.07-1.46; p = 0.005). Within this group, with a relative decrease in Pa co2 greater than 30%, the effects of increased relative MAP increased neurologic complications (0.05% per BP Percentile; 95% CI, 0.001-0.11; p = 0.05). CONCLUSIONS In pediatric patients, a large decrease in Pa co2 and increase in MAP following ECMO initiation are both associated with neurologic complications. Future research focusing on managing these issues carefully soon after ECMO deployment can potentially help to reduce neurologic complications.
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Affiliation(s)
- Neel Shah
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Xilong Li
- Department of Population and Data Science, University of Texas Southwestern Medical Center, Dallas, TX
| | - Prashanth Shanmugham
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
| | | | | | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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9
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Sanford EL, Akorede R, Miller I, Morriss MC, Nandy K, Raman L, Busch DR. Association Between Disrupted Cerebral Autoregulation and Radiographic Neurologic Injury for Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study. ASAIO J 2023; 69:e315-e321. [PMID: 37172001 DOI: 10.1097/mat.0000000000001970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Validation of a real-time monitoring device to evaluate the risk or occurrence of neurologic injury while on extracorporeal membrane oxygenation (ECMO) may aid clinicians in prevention and treatment. Therefore, we performed a pilot prospective cohort study of children under 18 years old on ECMO to analyze the association between cerebral blood pressure autoregulation as measured by diffuse correlation spectroscopy (DCS) and radiographic neurologic injury. DCS measurements of regional cerebral blood flow were collected on enrolled patients and correlated with mean arterial blood pressure to determine the cerebral autoregulation metric termed DCSx. The primary outcome of interest was radiographic neurologic injury on eligible computed tomography (CT) or magnetic resonance imaging (MRI) scored by a blinded pediatric neuroradiologist utilizing a previously validated scale. Higher DCSx scores, which indicate disruption of cerebral autoregulation, were associated with higher radiographic neurologic injury score (slope, 11.0; 95% confidence interval [CI], 0.29-22). Patients with clinically significant neurologic injury scores of 10 or more had higher median DCSx measures than patients with lower neurologic injury scores (0.48 vs . 0.13; p = 0.01). Our study indicates that obtaining noninvasive DCS measures for children on ECMO is feasible and disruption of cerebral autoregulation determined from DCS is associated with higher radiographic neurologic injury score.
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Affiliation(s)
- Ethan L Sanford
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Rufai Akorede
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Isabel Miller
- UT Southwestern Medical Center Medical School, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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10
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Zhang Y, Zhang M. Systemic inflammatory response syndrome-mediated neuronal plasticity in the central nervous system contributes to neurocognitive complications of extracorporeal membrane oxygenation. ALL LIFE 2022. [DOI: 10.1080/26895293.2022.2154857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ying Zhang
- Department of Cardiovascular Surgery, Xi’an International Medical Center Hospital, Xi’an, People’s Republic of China
| | - Ming Zhang
- Department of Basic Medical Laboratory, The General Hospital of Western Theater Command, Chengdu, People’s Republic of China
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11
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Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation. ASAIO J 2022; 69:411-416. [PMID: 36730940 PMCID: PMC10044589 DOI: 10.1097/mat.0000000000001838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The primary objective was to investigate the association between partial pressure of carbon dioxide (PaCO2) change after extracorporeal membrane oxygenation (ECMO) initiation and neurologic outcome in neonates treated for respiratory failure. A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database including newborns supported by ECMO for respiratory indication during 2015-2020. The closest Pre-ECMO (Pre-ECMO PaCO2) and at 24 hours after ECMO initiation (H24 PaCO2) PaCO2 values allowed to calculate the relative change in PaCO2 (Rel Δ PaCO2 = [H24 PaCO2 - Pre-ECMO PaCO2]/Pre-ECMO PaCO2). The primary outcome was the onset of any acute neurologic event (ANE), defined as cerebral bleeding, ischemic stroke, clinical or electrical seizure, or brain death during ECMO. We included 3,583 newborns (median age 1 day [interquartile range {IQR}, 1-3], median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers. The median Rel Δ PaCO2 value was -29.9% [IQR, -46.2 to -8.5]. Six hundred nine (17%) of them had ANE (405 cerebral bleedings, 111 ischemic strokes, 225 seizures, and 6 brain deaths). Patients with a decrease of PaCO2 > 50% were more likely to develop ANE than others (odds ratio [OR] 1.78, 95% confidence interval [CI], 1.31-2.42, p < 0.001). This was still observed after adjustment for all clinically relevant confounding factors (adjusted OR 1.94, 95% CI, 1.29-2.92, p = 0.001). A significant decrease in PaCO2 after ECMO start is associated with ANE among neonates requiring ECMO for respiratory failure. Cautious PaCO2 decrease should be considered after start of ECMO therapy.
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12
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Ayaz H, Baker WB, Blaney G, Boas DA, Bortfeld H, Brady K, Brake J, Brigadoi S, Buckley EM, Carp SA, Cooper RJ, Cowdrick KR, Culver JP, Dan I, Dehghani H, Devor A, Durduran T, Eggebrecht AT, Emberson LL, Fang Q, Fantini S, Franceschini MA, Fischer JB, Gervain J, Hirsch J, Hong KS, Horstmeyer R, Kainerstorfer JM, Ko TS, Licht DJ, Liebert A, Luke R, Lynch JM, Mesquida J, Mesquita RC, Naseer N, Novi SL, Orihuela-Espina F, O’Sullivan TD, Peterka DS, Pifferi A, Pollonini L, Sassaroli A, Sato JR, Scholkmann F, Spinelli L, Srinivasan VJ, St. Lawrence K, Tachtsidis I, Tong Y, Torricelli A, Urner T, Wabnitz H, Wolf M, Wolf U, Xu S, Yang C, Yodh AG, Yücel MA, Zhou W. Optical imaging and spectroscopy for the study of the human brain: status report. NEUROPHOTONICS 2022; 9:S24001. [PMID: 36052058 PMCID: PMC9424749 DOI: 10.1117/1.nph.9.s2.s24001] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
This report is the second part of a comprehensive two-part series aimed at reviewing an extensive and diverse toolkit of novel methods to explore brain health and function. While the first report focused on neurophotonic tools mostly applicable to animal studies, here, we highlight optical spectroscopy and imaging methods relevant to noninvasive human brain studies. We outline current state-of-the-art technologies and software advances, explore the most recent impact of these technologies on neuroscience and clinical applications, identify the areas where innovation is needed, and provide an outlook for the future directions.
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Affiliation(s)
- Hasan Ayaz
- Drexel University, School of Biomedical Engineering, Science, and Health Systems, Philadelphia, Pennsylvania, United States
- Drexel University, College of Arts and Sciences, Department of Psychological and Brain Sciences, Philadelphia, Pennsylvania, United States
| | - Wesley B. Baker
- Children’s Hospital of Philadelphia, Division of Neurology, Philadelphia, Pennsylvania, United States
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Giles Blaney
- Tufts University, Department of Biomedical Engineering, Medford, Massachusetts, United States
| | - David A. Boas
- Boston University Neurophotonics Center, Boston, Massachusetts, United States
- Boston University, College of Engineering, Department of Biomedical Engineering, Boston, Massachusetts, United States
| | - Heather Bortfeld
- University of California, Merced, Departments of Psychological Sciences and Cognitive and Information Sciences, Merced, California, United States
| | - Kenneth Brady
- Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Department of Anesthesiology, Chicago, Illinois, United States
| | - Joshua Brake
- Harvey Mudd College, Department of Engineering, Claremont, California, United States
| | - Sabrina Brigadoi
- University of Padua, Department of Developmental and Social Psychology, Padua, Italy
| | - Erin M. Buckley
- Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia, United States
| | - Stefan A. Carp
- Massachusetts General Hospital, Harvard Medical School, Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, United States
| | - Robert J. Cooper
- University College London, Department of Medical Physics and Bioengineering, DOT-HUB, London, United Kingdom
| | - Kyle R. Cowdrick
- Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
| | - Joseph P. Culver
- Washington University School of Medicine, Department of Radiology, St. Louis, Missouri, United States
| | - Ippeita Dan
- Chuo University, Faculty of Science and Engineering, Tokyo, Japan
| | - Hamid Dehghani
- University of Birmingham, School of Computer Science, Birmingham, United Kingdom
| | - Anna Devor
- Boston University, College of Engineering, Department of Biomedical Engineering, Boston, Massachusetts, United States
| | - Turgut Durduran
- ICFO – The Institute of Photonic Sciences, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
- Institució Catalana de Recerca I Estudis Avançats (ICREA), Barcelona, Spain
| | - Adam T. Eggebrecht
- Washington University in St. Louis, Mallinckrodt Institute of Radiology, St. Louis, Missouri, United States
| | - Lauren L. Emberson
- University of British Columbia, Department of Psychology, Vancouver, British Columbia, Canada
| | - Qianqian Fang
- Northeastern University, Department of Bioengineering, Boston, Massachusetts, United States
| | - Sergio Fantini
- Tufts University, Department of Biomedical Engineering, Medford, Massachusetts, United States
| | - Maria Angela Franceschini
- Massachusetts General Hospital, Harvard Medical School, Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, United States
| | - Jonas B. Fischer
- ICFO – The Institute of Photonic Sciences, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - Judit Gervain
- University of Padua, Department of Developmental and Social Psychology, Padua, Italy
- Université Paris Cité, CNRS, Integrative Neuroscience and Cognition Center, Paris, France
| | - Joy Hirsch
- Yale School of Medicine, Department of Psychiatry, Neuroscience, and Comparative Medicine, New Haven, Connecticut, United States
- University College London, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
| | - Keum-Shik Hong
- Pusan National University, School of Mechanical Engineering, Busan, Republic of Korea
- Qingdao University, School of Automation, Institute for Future, Qingdao, China
| | - Roarke Horstmeyer
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
- Duke University, Department of Electrical and Computer Engineering, Durham, North Carolina, United States
- Duke University, Department of Physics, Durham, North Carolina, United States
| | - Jana M. Kainerstorfer
- Carnegie Mellon University, Department of Biomedical Engineering, Pittsburgh, Pennsylvania, United States
- Carnegie Mellon University, Neuroscience Institute, Pittsburgh, Pennsylvania, United States
| | - Tiffany S. Ko
- Children’s Hospital of Philadelphia, Division of Cardiothoracic Anesthesiology, Philadelphia, Pennsylvania, United States
| | - Daniel J. Licht
- Children’s Hospital of Philadelphia, Division of Neurology, Philadelphia, Pennsylvania, United States
| | - Adam Liebert
- Polish Academy of Sciences, Nalecz Institute of Biocybernetics and Biomedical Engineering, Warsaw, Poland
| | - Robert Luke
- Macquarie University, Department of Linguistics, Sydney, New South Wales, Australia
- Macquarie University Hearing, Australia Hearing Hub, Sydney, New South Wales, Australia
| | - Jennifer M. Lynch
- Children’s Hospital of Philadelphia, Division of Cardiothoracic Anesthesiology, Philadelphia, Pennsylvania, United States
| | - Jaume Mesquida
- Parc Taulí Hospital Universitari, Critical Care Department, Sabadell, Spain
| | - Rickson C. Mesquita
- University of Campinas, Institute of Physics, Campinas, São Paulo, Brazil
- Brazilian Institute of Neuroscience and Neurotechnology, Campinas, São Paulo, Brazil
| | - Noman Naseer
- Air University, Department of Mechatronics and Biomedical Engineering, Islamabad, Pakistan
| | - Sergio L. Novi
- University of Campinas, Institute of Physics, Campinas, São Paulo, Brazil
- Western University, Department of Physiology and Pharmacology, London, Ontario, Canada
| | | | - Thomas D. O’Sullivan
- University of Notre Dame, Department of Electrical Engineering, Notre Dame, Indiana, United States
| | - Darcy S. Peterka
- Columbia University, Zuckerman Mind Brain Behaviour Institute, New York, United States
| | | | - Luca Pollonini
- University of Houston, Department of Engineering Technology, Houston, Texas, United States
| | - Angelo Sassaroli
- Tufts University, Department of Biomedical Engineering, Medford, Massachusetts, United States
| | - João Ricardo Sato
- Federal University of ABC, Center of Mathematics, Computing and Cognition, São Bernardo do Campo, São Paulo, Brazil
| | - Felix Scholkmann
- University of Bern, Institute of Complementary and Integrative Medicine, Bern, Switzerland
- University of Zurich, University Hospital Zurich, Department of Neonatology, Biomedical Optics Research Laboratory, Zürich, Switzerland
| | - Lorenzo Spinelli
- National Research Council (CNR), IFN – Institute for Photonics and Nanotechnologies, Milan, Italy
| | - Vivek J. Srinivasan
- University of California Davis, Department of Biomedical Engineering, Davis, California, United States
- NYU Langone Health, Department of Ophthalmology, New York, New York, United States
- NYU Langone Health, Department of Radiology, New York, New York, United States
| | - Keith St. Lawrence
- Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
- Western University, Department of Medical Biophysics, London, Ontario, Canada
| | - Ilias Tachtsidis
- University College London, Department of Medical Physics and Biomedical Engineering, London, United Kingdom
| | - Yunjie Tong
- Purdue University, Weldon School of Biomedical Engineering, West Lafayette, Indiana, United States
| | - Alessandro Torricelli
- Politecnico di Milano, Dipartimento di Fisica, Milan, Italy
- National Research Council (CNR), IFN – Institute for Photonics and Nanotechnologies, Milan, Italy
| | - Tara Urner
- Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
| | - Heidrun Wabnitz
- Physikalisch-Technische Bundesanstalt (PTB), Berlin, Germany
| | - Martin Wolf
- University of Zurich, University Hospital Zurich, Department of Neonatology, Biomedical Optics Research Laboratory, Zürich, Switzerland
| | - Ursula Wolf
- University of Bern, Institute of Complementary and Integrative Medicine, Bern, Switzerland
| | - Shiqi Xu
- Duke University, Department of Biomedical Engineering, Durham, North Carolina, United States
| | - Changhuei Yang
- California Institute of Technology, Department of Electrical Engineering, Pasadena, California, United States
| | - Arjun G. Yodh
- University of Pennsylvania, Department of Physics and Astronomy, Philadelphia, Pennsylvania, United States
| | - Meryem A. Yücel
- Boston University Neurophotonics Center, Boston, Massachusetts, United States
- Boston University, College of Engineering, Department of Biomedical Engineering, Boston, Massachusetts, United States
| | - Wenjun Zhou
- University of California Davis, Department of Biomedical Engineering, Davis, California, United States
- China Jiliang University, College of Optical and Electronic Technology, Hangzhou, Zhejiang, China
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13
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Joram N, Beqiri E, Pezzato S, Andrea M, Robba C, Liet JM, Chenouard A, Bourgoin P, Czosnyka M, Léger PL, Smielewski P. Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO. Neurocrit Care 2021; 35:480-490. [PMID: 33686559 DOI: 10.1007/s12028-021-01201-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) impairment is associated with neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Severe variations of arterial CO2 (PaCO2) and O2 (PaO2) tension after ECMO onset are common and associate with mortality and poor neurological outcome. The impact of gas exchange on CA among critically ill patients is poorly studied. METHODS Retrospective analysis of data collected prospectively from 30 children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France. A correlation coefficient between the variations of regional cerebral oxygen saturation (rSO2) and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). Cox-MAP plots were investigated allowing determining lower limit of autoregulation (LLA) and upper limit of autoregulation (ULA) limits of autoregulation. Age-based normal blood pressure was used to adjust the MAP, LLA, and ULA data from each patient and then reported as percentage (nMAP, nLLA, and nULA, respectively). RSO2, COx, nMAP, nLLA, and nULA values were averaged over one hour before each arterial blood gas (ABG) sample during ECMO run. RESULTS Thirty children (median age 4.8 months [Interquartile range (IQR) 0.7-39.1], median weight 5 kg [IQR 4-15]) experiencing 31 ECMO runs were included in the study. Three hundred and ninety ABGs were analyzed. The highest values of COx were observed on day 1 (D1) of ECMO. The relationship between COx and PaCO2 was nonlinear, but COx values tended to be lower in case of hypercapnia compared to normocapnia. During the whole ECMO run, a weak but significant correlation between PaCO2 and nULA was observed (R = 0.432, p = 0.02). On D1 of ECMO, this correlation was stronger (R = 0.85, p = 0.03) and a positive correlation between nLLA and PaCO2 was also found (R = 0.726, p < 0.001). A very weak negative correlation between PaO2 and nULA was observed within the whole ECMO run and on D1 of ECMO (R = -0.07 p = 0.04 and R = -0.135 p = <0.001, respectively). The difference between nULA and nLLA representing the span of the autoregulation plateau was positively correlated with PaCO2 and negatively correlated with PaO2 (R = 0.224, p = 0.01 and R = -0.051, p = 0.004, respectively). CONCLUSIONS We observed a complex relationship between PaCO2 and CA, influenced by the level of blood pressure. Hypercapnia seems to be globally protective in normotensive or hypertensive condition, while, in case of very low MAP, hypercapnia may disturb CA as it increases LLA. These data add additional arguments for very cautiously lower PaCO2, especially after ECMO start.
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Affiliation(s)
- Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France. .,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France. .,INSERM U955-ENVA, University Paris 12, Paris, France.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Stefano Pezzato
- Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Moscatelli Andrea
- Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Chiara Robba
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Pierre-Louis Léger
- INSERM U955-ENVA, University Paris 12, Paris, France.,Pediatric Intensive Care Unit, Trousseau University Hospital, Paris, France
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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14
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Jawa NA, Holden RM, Silver SA, Scott SH, Day AG, Norman PA, Kwan BYM, Maslove DM, Muscedere J, Boyd JG. Identifying neurocognitive outcomes and cerebral oxygenation in critically ill adults on acute kidney replacement therapy in the intensive care unit: the INCOGNITO-AKI study protocol. BMJ Open 2021; 11:e049250. [PMID: 34404711 PMCID: PMC8372874 DOI: 10.1136/bmjopen-2021-049250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Initiation of acute kidney replacement therapy (KRT) is common in critically ill adults admitted to the intensive care unit (ICU), and associated with increased morbidity and mortality. KRT has been linked to poor neurocognitive outcomes, leading to reduced quality of life and increased utilisation of healthcare resources. Adults on dialysis in the ICU may be particularly at risk of neurocognitive impairment, as survivors of critical illness are already predisposed to developing cerebrovascular disease and cognitive dysfunction long-term relative to healthy controls. Regional cerebral oxygen saturation may provide a critical early marker of long-term neurocognitive impairment in this population. This study aims to understand cerebral oxygenation in patients undergoing KRT (continuous or intermittent) in the ICU. These findings will be correlated with long-term cognitive and functional outcomes, and structural brain pathology. METHODS AND ANALYSIS 108 patients scheduled to undergo treatment for acute kidney injury with KRT in the Kingston Health Sciences Centre ICU will be recruited into this prospective observational study. Enrolled patients will be assessed with intradialytic cerebral oximetry using near infrared spectroscopy. Delirium will be assessed daily with the Confusion Assessment Method-ICU (CAM-ICU) and severity quantified as cumulative CAM-ICU-7 scores. Neurocognitive impairment will be assessed at 3 and 12 months after hospital discharge using the Kinarm and Repeatable Battery for the Assessment of Neuropsychological Status. Structural brain pathology on MRI will also be measured at the same timepoints. Driving safety, adverse events and medication adherence will be assessed at 12 months to evaluate the impact of neurocognitive impairment on functional outcomes. ETHICS AND DISSEMINATION This study is approved by the Queen's University Health Sciences/Affiliated Teaching Hospitals Research Ethics Board (DMED-2424-20). Results will be presented at critical care conferences, and a lay summary will be provided to patients in their preferred format. TRIAL REGISTRATION NUMBER NCT04722939.
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Affiliation(s)
| | - Rachel M Holden
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Samuel A Silver
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Stephen H Scott
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Andrew G Day
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
- Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Patrick A Norman
- Kingston General Health Research Institute, Kingston, Ontario, Canada
| | - Benjamin Y M Kwan
- Department of Diagnostic Radiology, Queen's University, Kingston, Ontario, Canada
| | - David M Maslove
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - John Muscedere
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - John Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
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15
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Khan IR, Gu Y, George BP, Malone L, Conway KS, Francois F, Donlon J, Quazi N, Reddi A, Ho CY, Herr DL, Johnson MD, Parikh GY. Brain Histopathology of Adult Decedents After Extracorporeal Membrane Oxygenation. Neurology 2021; 96:e1278-e1289. [PMID: 33472914 DOI: 10.1212/wnl.0000000000011525] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To test the hypothesis that brain injury is more common and varied in patients receiving extracorporeal membrane oxygenation (ECMO) than radiographically observed, we described neuropathology findings of ECMO decedents and associated clinical factors from 3 institutions. METHODS We conducted a retrospective multicenter observational study of brain autopsies from adult ECMO recipients. Pathology findings were examined for correlation with demographics, clinical data, ECMO characteristics, and outcomes. RESULTS Forty-three decedents (n = 13 female, median age 47 years) received autopsies after undergoing ECMO for acute respiratory distress syndrome (n = 14), cardiogenic shock (n = 14), and cardiac arrest (n = 15). Median duration of ECMO was 140 hours, most decedents (n = 40) received anticoagulants; 60% (n = 26) underwent venoarterial ECMO, and 40% (n = 17) underwent venovenous ECMO. Neuropathology was found in 35 decedents (81%), including microhemorrhages (37%), macrohemorrhages (35%), infarctions (47%), and hypoxic-ischemic brain injury (n = 17, 40%). Most pathology occurred in frontal neocortices (n = 43 occurrences), basal ganglia (n = 33), and cerebellum (n = 26). Decedents with hemorrhage were older (median age 57 vs 38 years, p = 0.01); those with hypoxic brain injury had higher Sequential Organ Failure Assessment scores (8.0 vs 2.0, p = 0.04); and those with infarction had lower peak Paco2 (53 vs 61 mm Hg, p = 0.04). Six of 9 patients with normal neuroimaging results were found to have pathology on autopsy. The majority underwent withdrawal of life-sustaining therapy (n = 32, 74%), and 2 of 8 patients with normal brain autopsy underwent withdrawal of life-sustaining therapy for suspected neurologic injury. CONCLUSION Neuropathological findings after ECMO are common, varied, and associated with various clinical factors. Further study on underlying mechanisms is warranted and may guide ECMO management.
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Affiliation(s)
- Imad R Khan
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY.
| | - Yang Gu
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Benjamin P George
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Laura Malone
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Kyle S Conway
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Fabienne Francois
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Jack Donlon
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Nadim Quazi
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Ashwin Reddi
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Cheng-Ying Ho
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Daniel L Herr
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Mahlon D Johnson
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
| | - Gunjan Y Parikh
- From the Department of Neurology (I.R.K., B.P.G.), Division of Neurocritical Care, and Department of Anesthesiology and Perioperative Medicine (Y.G.), University of Rochester Medical Center, NY; Department of Pathology (L.M., C.-Y.H.), University of Maryland Medical Center, Baltimore; Department of Pathology (K.S.C.), University of Michigan School of Medicine, Ann Arbor; Cardiac Surgery Research (F.F.), University of Maryland School of Medicine, Baltimore; College of Arts & Sciences (J.D., N.Q.), University of Rochester, NY; University of Maryland School of Medicine (A.R.); Program in Trauma and Critical Care (D.L.H.), Department of Medicine, and Program in Trauma (G.Y.P.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore; and Department of Pathology and Laboratory Medicine (M.D.J.), University of Rochester School of Medicine & Dentistry, NY
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Chen S, Fang F, Liu W, Liu C, Xu F. Cerebral Tissue Regional Oxygen Saturation as a Valuable Monitoring Parameter in Pediatric Patients Undergoing Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:669683. [PMID: 34178887 PMCID: PMC8220806 DOI: 10.3389/fped.2021.669683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: Brain function monitoring technology for extracorporeal membrane oxygenation (ECMO) support has been developing quite slowly. Our objective was to explore the data distribution, variation trend, and variability of cerebral tissue regional oxygen saturation (CrSO2) in pediatric patients undergoing ECMO. Methods: Eight patients who received venoarterial ECMO (V-A ECMO) were included in our study. All of them accepted continuous CrSO2 monitoring by near-infrared spectroscopy (NIRS) within 12 h of ECMO initiation until ECMO wean. Differences in the CrSO2 distribution characteristic, the variation trend of daily CrSO2, and the variability of CrSO2 for the first 5 days following ECMO initiation were compared between survivors and non-survivors according to pediatric intensive care unit (PICU) mortality. Results: The percentage of time of CrSO2 <60% against the whole monitoring time was significantly lower in survivors in both hemispheres {right: 4.34% [interquartile range (IQR) = 0.39-8.55%] vs. 47.45% [IQR = 36.03-64.52%], p = 0.036; left: 0.40% [IQR = 0.01-1.15%] vs. 30.9% [IQR = 26.92-49.62%], p = 0.036}. Survivors had significantly higher CrSO2 on the first 4 days. Root mean of successive squared differences (RMSSD), the variability variable of CrSO2, was significantly lower in survivors (right: 3.29 ± 0.79 vs. 6.16 ± 0.67, p = 0.002; left: 3.56 ± 1.20 vs. 6.04 ± 1.44, p = 0.039). Conclusion: Lower CrSO2, CrSO2 <60% over a longer period of time, and higher fluctuation of CrSO2 are likely associated with PICU mortality in pediatric patients undergoing V-A ECMO. Clinical Trial Registry: URL: http://www.chictr.org.cn/showproj.aspx?proj=46639, trial registry number: ChiCTR1900028021.
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Affiliation(s)
- Song Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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17
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Busch DR, Baker WB, Mavroudis CD, Ko TS, Lynch JM, McCarthy AL, DuPont-Thibodeau G, Buckley EM, Jacobwitz M, Boorady TW, Mensah-Brown K, Connelly JT, Yodh AG, Kilbaugh TJ, Licht DJ. Noninvasive optical measurement of microvascular cerebral hemodynamics and autoregulation in the neonatal ECMO patient. Pediatr Res 2020; 88:925-933. [PMID: 32172282 PMCID: PMC7492409 DOI: 10.1038/s41390-020-0841-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Extra-corporeal membrane oxygenation (ECMO) is a life-saving intervention for severe respiratory and cardiac diseases. However, 50% of survivors have abnormal neurologic exams. Current ECMO management is guided by systemic metrics, which may poorly predict cerebral perfusion. Continuous optical monitoring of cerebral hemodynamics during ECMO holds potential to detect risk factors of brain injury such as impaired cerebrovascular autoregulation (CA). METHODS We conducted daily measurements of microvascular cerebral blood flow (CBF), oxygen saturation, and total hemoglobin concentration using diffuse correlation spectroscopy (DCS) and frequency-domain diffuse optical spectroscopy in nine neonates. We characterize CA utilizing the correlation coefficient (DCSx) between CBF and mean arterial blood pressure (MAP) during ECMO pump flow changes. RESULTS Average MAP and pump flow levels were weakly correlated with CBF and were not correlated with cerebral oxygen saturation. CA integrity varied between individuals and with time. Systemic measurements of MAP, pulse pressure, and left cardiac dysfunction were not predictive of impaired CA. CONCLUSIONS Our pilot results suggest that systemic measures alone cannot distinguish impaired CA from intact CA during ECMO. Furthermore, optical neuromonitoring could help determine patient-specific ECMO pump flows for optimal CA integrity, thereby reducing risk of secondary brain injury. IMPACT Cerebral blood flow and oxygenation are not well predicted by systemic proxies such as ECMO pump flow or blood pressure. Continuous, quantitative, bedside monitoring of cerebral blood flow and oxygenation with optical tools enables new insight into the adequacy of cerebral perfusion during ECMO. A demonstration of hybrid diffuse optical and correlation spectroscopies to continuously measure cerebral blood oxygen saturation and flow in patients on ECMO, enabling assessment of cerebral autoregulation. An observation of poor correlation of cerebral blood flow and oxygenation with systemic mean arterial pressure and ECMO pump flow, suggesting that clinical decision making guided by target values for these surrogates may not be neuroprotective. ~50% of ECMO survivors have long-term neurological deficiencies; continuous monitoring of brain health throughout therapy may reduce these tragically common sequelae through brain-focused adjustment of ECMO parameters.
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Affiliation(s)
- David R Busch
- Departments of Anesthesiology & Pain Management and Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wesley B Baker
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tiffany S Ko
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Lynch
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ann L McCarthy
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy W Boorady
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kobina Mensah-Brown
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James T Connelly
- ECMO Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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18
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Continuous Monitoring of Cerebral Autoregulation in Children Supported by Extracorporeal Membrane Oxygenation: A Pilot Study. Neurocrit Care 2020; 34:935-945. [PMID: 33029743 DOI: 10.1007/s12028-020-01111-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Cerebral autoregulation (CA) impairment may pose a risk factor for neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Our first objective was to investigate the feasibility of CA continuous monitoring during ECMO treatment and to describe its evolution over time. The second objective was to analyze the association between CA impairment and neurological outcome. DESIGN Observational prospective study. PATIENTS AND SETTING Twenty-nine children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France, and the PICU of the IRCCS Giannina Gaslini Institute in Genoa, Italy. MEASUREMENTS A correlation coefficient between the variations of regional cerebral oxygen saturation and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). A COx > 0.3 was considered as indicative of autoregulation impairment. COx-MAP plots were investigated allowing determining optimal MAP (MAPopt) and limits of autoregulation: lower (LLA) and upper (ULA). Neurological outcome was assessed by the onset of an acute neurological event (ANE) after ECMO start. RESULTS We included 29 children (median age 84 days, weight 4.8 kg). MAPopt, LLA, and ULA were detected in 90.8% (84.3-93.3) of monitoring time. Mean COx was significantly higher during day 1 of ECMO compared to day 2 [0.1 (0.02-0.15) vs. 0.01 (- 0.05 to 0.1), p = 0.002]. Twelve children experienced ANE (34.5%). The mean COx and the percentage of time spent with a COx > 0.3 were significantly higher among ANE+ compared to ANE- patients [0.09 (0.01-0.23) vs. 0.04 (- 0.02 to 0.06), p = 0.04 and 33.3% (24.8-62.1) vs. 20.8% (17.3-23.7) p = 0.001]. ANE+ patients spent significantly more time with MAP below LLA [17.2% (6.5-32.9) vs. 5.6% (3.6-9.9), p = 0.02] and above ULA [13% (5.3-38.4) vs. 4.2% (2.7-7.4), p = 0.004], respectively. CONCLUSION CA assessment is feasible in pediatric ECMO. The first 24 h following ECMO represents the most critical period regarding CA. Impaired autoregulation is significantly more severe among patients who experience ANE.
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Cerebral Hemodynamic Profile in Ischemic and Hemorrhagic Brain Injury Acquired During Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:879-885. [PMID: 32569240 DOI: 10.1097/pcc.0000000000002438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the cerebral hemodynamic profiles associated with ischemic and hemorrhagic brain injury during neonatal and pediatric extracorporeal membrane oxygenation. DESIGN A retrospective cohort study. SETTING Tertiary PICU. PATIENTS Forty-seven neonatal and pediatric patients (0-15 yr of age) placed on extracorporeal membrane oxygenation from January 2014 to December 2018. MEASUREMENTS AND MAIN RESULTS Continuous monitoring of mean arterial pressure and cerebral tissue oxygen saturation was conducted through entire extracorporeal membrane oxygenation run. Wavelet analysis was performed to assess changes in cerebral autoregulation and to derive pressure-dependent autoregulation curves based on the mean arterial pressure and cerebral tissue oxygen saturation data. Patients were classified into three brain injury groups: no-injury, ischemic injury, and hemorrhagic injury based on neuroimaging results. No-injury patients (n = 23) had minimal variability in the autoregulation curve over a broad range of blood pressure. Ischemic injury (n = 16) was more common than hemorrhagic injury (n = 8), and the former was associated with increased mortality and morbidity. Ischemic group showed significant abnormalities in cerebral autoregulation in the lower blood pressure range, suggesting pressure-dependent cerebral perfusion. Hemorrhagic group had highest average blood pressure as well as the lowest cerebral tissue oxygenation saturation, suggesting elevated cerebral vascular resistance. Mean heparin dose during extracorporeal membrane oxygenation was lower in both ischemic and hemorrhagic groups compared with the no-injury group. CONCLUSIONS This study outlines distinct differences in underlying cerebral hemodynamics associated with ischemic and hemorrhagic brain injury acquired during extracorporeal membrane oxygenation. Real-time monitoring of cerebral hemodynamics in patients acquiring brain injury during extracorporeal membrane oxygenation can help optimize their management.
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Abstract
Neurologic injury is a known and feared complication of extracorporeal membrane oxygenation (ECMO). Neurologic biomarkers may have a role in assisting in early identification of such. Axonal biomarker tau has not been investigated in the pediatric ECMO population. The objective of this study is to evaluate plasma levels of tau in pediatric patients supported with ECMO. Eighteen patients requiring ECMO support in a quaternary pediatric intensive care unit at a university-affiliated children's hospital from October 2015 to February 2017 were enrolled. Patients undergoing extracorporeal cardiopulmonary resuscitation or recent history of bypass were excluded. Plasma tau was measured using enzyme-linked immunosorbent assay. Neuroimaging was reviewed for acute neurologic injury, and tau levels were analyzed to assess for correlation. Tau was significantly higher in ECMO patients than in control subjects. Sixty-one percent of subjects had evidence of acute brain injury on neuroimaging, but tau level did not correlate with injury. Subjects with multifocal injury all experienced infarction and had significantly higher tau levels on ECMO day 3 than patients with isolated injury. In addition, peak tau levels of neuro-injured subjects were compared with controls and noninjured ECMO subjects using receiver operating curve analysis. This study demonstrates preliminary evidence of axonal injury in pediatric ECMO patients.
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A Pilot Study Identifying Brain-Targeting Adaptive Immunity in Pediatric Extracorporeal Membrane Oxygenation Patients With Acquired Brain Injury. Crit Care Med 2020; 47:e206-e213. [PMID: 30640221 PMCID: PMC6377324 DOI: 10.1097/ccm.0000000000003621] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: Extracorporeal membrane oxygenation provides short-term cardiopulmonary life support, but is associated with peripheral innate inflammation, disruptions in cerebral autoregulation, and acquired brain injury. We tested the hypothesis that extracorporeal membrane oxygenation also induces CNS-directed adaptive immune responses which may exacerbate extracorporeal membrane oxygenation-associated brain injury. Design: A single center prospective observational study. Setting: Pediatric and cardiac ICUs at a single tertiary care, academic center. Patients: Twenty pediatric extracorporeal membrane oxygenation patients (0–14 yr; 13 females, 7 males) and five nonextracorporeal membrane oxygenation Pediatric Logistic Organ Dysfunction score matched patients Interventions: None. Measurements and Main Results: Venous blood samples were collected from the extracorporeal membrane oxygenation circuit at day 1 (10–23 hr), day 3, and day 7 of extracorporeal membrane oxygenation. Flow cytometry quantified circulating innate and adaptive immune cells, and CNS-directed autoreactivity was detected using an in vitro recall response assay. Disruption of cerebral autoregulation was determined using continuous bedside near-infrared spectroscopy and acquired brain injury confirmed by MRI. Extracorporeal membrane oxygenation patients with acquired brain injury (n = 9) presented with a 10-fold increase in interleukin-8 over extracorporeal membrane oxygenation patients without brain injury (p < 0.01). Furthermore, brain injury within extracorporeal membrane oxygenation patients potentiated an inflammatory phenotype in adaptive immune cells and selective autoreactivity to brain peptides in circulating B cell and cytotoxic T cell populations. Correlation analysis revealed a significant relationship between adaptive immune responses of extracorporeal membrane oxygenation patients with acquired brain injury and loss of cerebral autoregulation. Conclusions: We show that pediatric extracorporeal membrane oxygenation patients with acquired brain injury exhibit an induction of pro-inflammatory cell signaling, a robust activation of adaptive immune cells, and CNS-targeting adaptive immune responses. As these patients experience developmental delays for years after extracorporeal membrane oxygenation, it is critical to identify and characterize adaptive immune cell mechanisms that target the developing CNS.
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Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management. Crit Care Res Pract 2018; 2018:3237810. [PMID: 29744226 PMCID: PMC5878897 DOI: 10.1155/2018/3237810] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.
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