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Spilka JM, O'Halloran CP, Marino BS, Brady KM. Perspective on Cerebral Autoregulation Monitoring in Neonatal Cardiac Surgery Requiring Cardiopulmonary Bypass. Front Neurol 2021; 12:740185. [PMID: 34675872 PMCID: PMC8523884 DOI: 10.3389/fneur.2021.740185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/09/2021] [Indexed: 11/23/2022] Open
Abstract
The autoregulation of cerebral blood flow protects against brain injury from transient fluctuations in arterial blood pressure. Impaired autoregulation may contribute to hypoperfusion injury in neonates and infants. Monitoring cerebral autoregulation in neonatal cardiac surgery as a guide for arterial blood pressure management may reduce neurodevelopmental morbidity. Cerebral autoregulation monitoring has been validated in animal models and in an adult trial autoregulation monitoring during bypass improved postoperative delirium scores. The nuances of pediatric cardiac disease and congenital heart surgery make simply applying adult trial findings to this unique population inappropriate. Therefore, dedicated pediatric clinical trials of cerebral autoregulation monitoring are indicated.
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Affiliation(s)
- Jared M Spilka
- Division of Cardiac Anesthesia, Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Conor P O'Halloran
- Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH, United States
| | - Kenneth M Brady
- Division of Cardiac Anesthesia, Department of Anesthesiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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Massaro AN, Lee JK, Vezina G, Glass P, O'Kane A, Li R, Chang T, Brady K, Govindan R. Exploratory Assessment of the Relationship Between Hemoglobin Volume Phase Index, Magnetic Resonance Imaging, and Functional Outcome in Neonates with Hypoxic-Ischemic Encephalopathy. Neurocrit Care 2020; 35:121-129. [PMID: 33215394 DOI: 10.1007/s12028-020-01150-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVE Near-infrared spectroscopy (NIRS)-based measures of cerebral autoregulation (CAR) can potentially identify neonates with hypoxic-ischemic encephalopathy (HIE) who are at greatest risk of irreversible brain injury. However, modest predictive abilities have precluded previously described metrics from entering clinical care. We previously validated a novel autoregulation metric in a piglet model of induced hypotension called the hemoglobin volume phase index (HVP). The objective of this study was to evaluate the clinical ability of the HVP to predict adverse outcomes neonates with HIE. METHODS This is a prospective study of neonates with HIE who underwent therapeutic hypothermia (TH) at a level 4 neonatal intensive care unit (NICU). Continuous cerebral NIRS and mean arterial blood pressure (MAP) from indwelling arterial catheters were measured during TH and through rewarming. Multivariate autoregressive process was used to calculate the coherence between MAP and the sum total of the oxy- and deoxygenated Hb densities (HbT), a surrogate measure of cerebral blood volume (CBV). The HVP was calculated as the cosine-transformed phase shift at the frequency of maximal MAP-HbT coherence. Brain injury was assessed by neonatal magnetic resonance imaging (MRI), and developmental outcomes were assessed by the Bayley Scales of Infant Development (BSID-III) at 15-30 months. The ability of the HVP to predict (a) death or severe brain injury by MRI and (b) death or significant developmental delay was assessed using logistic regression analyses. RESULTS In total, 50 neonates with moderate or severe HIE were monitored. Median HVP was higher, representing more dysfunctional autoregulation, in infants who had adverse outcomes. After adjusting for sex and encephalopathy grade at presentation, HVP at 21-24 and 24-27 h of life predicted death or brain injury by MRI (21-24 h: OR 8.8, p = 0.037; 24-27 h: OR 31, p = 0.011) and death or developmental delay at 15-30 months (21-24 h: OR 11.8, p = 0.05; 24-27 h: OR 15, p = 0.035). CONCLUSIONS Based on this pilot study of neonates with HIE, HVP merits further study as an indicator of death or severe brain injury on neonatal MRI and neurodevelopmental delay in early childhood. Larger studies are warranted for further clinical validation of the HVP to evaluate cerebral autoregulation following HIE.
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Affiliation(s)
- An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA. .,The George Washington University School of Medicine, Washington, DC, USA.
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gilbert Vezina
- Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | - Penny Glass
- Psychology and Behavioral Health, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | | | - Ruoying Li
- Neurology, Children's National Hospital, Washington, DC, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | - Kenneth Brady
- Department of Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rathinaswamy Govindan
- Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
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Ferlini L, Su F, Creteur J, Taccone FS, Gaspard N. Cerebral autoregulation and neurovascular coupling are progressively impaired during septic shock: an experimental study. Intensive Care Med Exp 2020; 8:44. [PMID: 32797301 PMCID: PMC7426896 DOI: 10.1186/s40635-020-00332-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Background Alteration of the mechanisms of cerebral blood flow (CBF) regulation might contribute to the pathophysiology of sepsis-associated encephalopathy (SAE). However, previous clinical studies on dynamic cerebral autoregulation (dCA) in sepsis had several cofounders. Furthermore, little is known on the potential impairment of neurovascular coupling (NVC) in sepsis. The aim of our study was to determine the presence and time course of dCA and NVC alterations in a clinically relevant animal model and their potential impact on the development of SAE. Methods Thirty-six anesthetized, mechanically ventilated female sheep were randomized to sham procedures (sham, n = 15), sepsis (n = 14), or septic shock (n = 7). Blood pressure, CBF, and electrocorticography were continuously recorded. Pearson’s correlation coefficient Lxa and transfer function analysis were used to estimate dCA. NVC was assessed by the analysis of CBF variations induced by cortical gamma activity (Eγ) peaks and by the magnitude-squared coherence (MSC) between the spontaneous fluctuations of CBF and Eγ. Cortical function was estimated by the alpha-delta ratio. Wilcoxon signed rank and rank sum tests, Friedman tests, and RMANOVA test were used as appropriate. Results Sepsis and sham animals did not differ neither in dCA nor in NVC parameters. A significant impairment of dCA occurred only after septic shock (Lxa, p = 0.03, TFA gain p = 0.03, phase p = 0.01). Similarly, NVC was altered during septic shock, as indicated by a lower MSC in the frequency band 0.03–0.06 Hz (p < 0.001). dCA and NVC impairments were associated with cortical dysfunction (reduction in the alpha-delta ratio (p = 0.03)). Conclusions A progressive loss of dCA and NVC occurs during septic shock and is associated with cortical dysfunction. These findings indicate that the alteration of mechanisms controlling cortical perfusion plays a late role in the pathophysiology of SAE and suggest that alterations of CBF regulation mechanisms in less severe phases of sepsis reported in clinical studies might be due to patients’ comorbidities or other confounders. Furthermore, a mean arterial pressure targeting therapy aiming to optimize dCA might not be sufficient to prevent neuronal dysfunction in sepsis since it would not improve NVC.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Bruxelles, Belgium.
| | - Fuhong Su
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Bruxelles, Belgium
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Froese L, Dian J, Gomez A, Unger B, Zeiler FA. Cerebrovascular Response to Phenylephrine in Traumatic Brain Injury: A Scoping Systematic Review of the Human and Animal Literature. Neurotrauma Rep 2020; 1:46-62. [PMID: 34223530 PMCID: PMC8240891 DOI: 10.1089/neur.2020.0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous phenylephrine (PE) is utilized commonly in critical care for cardiovascular support. Its impact on the cerebrovasculature is unclear and its use may have important implications during states of critical neurological illness. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of PE in traumatic brain injury (TBI), evaluating both animal models and human studies. We searched MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to January 2020. We identified 12 studies with various animal models and 4 studies in humans with varying TBI pathology. There was a trend toward a consistent increase in mean arterial pressure (MAP) by the injection of PE systemically, and by proxy, an increase of the cerebral perfusion pressure (CPP). There was a consistent constriction of cerebral vessels by PE reported in the small number of studies documenting such a response. However, the heterogeneity of the literature on the CBF/cerebral blood volume (CBV) response makes the strength of the conclusions on PE limited. Studies were heterogeneous in design and had significant limitations, with most failing to adjust for confounding factors in cerebrovascular/CBF response. This review highlights the significant knowledge gap on the cerebrovascular/CBF effects of PE administration in TBI, calling for further study on the impact of PE on the cerebrovasculature both in vivo and in experimental settings.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Dian
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bertram Unger
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Center on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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Comparison of wavelet and correlation indices of cerebral autoregulation in a pediatric swine model of cardiac arrest. Sci Rep 2020; 10:5926. [PMID: 32245979 PMCID: PMC7125097 DOI: 10.1038/s41598-020-62435-8] [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] [Received: 10/24/2019] [Accepted: 03/13/2020] [Indexed: 02/07/2023] Open
Abstract
Existing cerebrovascular blood pressure autoregulation metrics have not been translated to clinical care for pediatric cardiac arrest, in part because signal noise causes high index time-variability. We tested whether a wavelet method that uses near-infrared spectroscopy (NIRS) or intracranial pressure (ICP) decreases index variability compared to that of commonly used correlation indices. We also compared whether the methods identify the optimal arterial blood pressure (ABPopt) and lower limit of autoregulation (LLA). 68 piglets were randomized to cardiac arrest or sham procedure with continuous monitoring of cerebral blood flow using laser Doppler, NIRS and ICP. The arterial blood pressure (ABP) was gradually reduced until it dropped to below the LLA. Several autoregulation indices were calculated using correlation and wavelet methods, including the pressure reactivity index (PRx and wPRx), cerebral oximetry index (COx and wCOx), and hemoglobin volume index (HVx and wHVx). Wavelet methodology had less index variability with smaller standard deviations. Both wavelet and correlation methods distinguished functional autoregulation (ABP above LLA) from dysfunctional autoregulation (ABP below the LLA). Both wavelet and correlation methods also identified ABPopt with high agreement. Thus, wavelet methodology using NIRS may offer an accurate vasoreactivity monitoring method with reduced signal noise after pediatric cardiac arrest.
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