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Fan TH, Premraj L, Roberts J, Lydston M, Robba C, Hager D, Suarez JI, Battaglini D, Cho SM. In-Hospital Neurologic Complications, Neuromonitoring, and Long-Term Neurologic Outcomes in Patients With Sepsis: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:452-463. [PMID: 37921513 PMCID: PMC10923122 DOI: 10.1097/ccm.0000000000006096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
OBJECTIVES Although delirium is well described in patients with sepsis, there are limited data on other neurologic complications. We aimed to systematically review the prevalence, neuromonitoring tools, and neurocognitive outcomes in sepsis patients with neurologic complications. DATA SOURCES MEDLINE and six other databases (Embase, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov ) were searched through January 2023. STUDY SELECTION Studies of adult patients with sepsis reported neurologic complications, use of neuromonitoring tools, neuropathology, and cognitive outcomes. DATA EXTRACTION Two independent reviewers extracted the data. Random-effect meta-analyses were used to pool data. DATA SYNTHESIS Seventy-four studies ( n = 146,855) were included. Neurologic complications were reported in 38 studies ( n = 142,193) including septic encephalopathy (36%, 95% CI, 27-46%; I 2 = 99%), ischemic stroke (5%, 95% CI, 2.1-11.5; I 2 = 99%), intracranial hemorrhage (2%, 95% CI, 1.0-4.4%; I 2 = 96%), seizures (1%, 95% CI, 0.2-7%; I 2 = 96%), posterior reversible encephalopathy syndrome (9%), and hypoxic-ischemic brain injury (7%). In the meta-regression analysis, pulmonary infection, sepsis induced by a gram-positive organism, higher sequential organ failure assessment score, acute physiology and chronic health evaluation II score at admission, and longer ICU length of stay were associated with higher risk of developing septic encephalopathy. Three studies ( n = 159) reported postmortem neuropathological findings, acute brain injury was noted in 47% of patients. Twenty-six studies ( n = 1,358) reported the use of neuromonitoring tools, electroencephalogram was the most used tool for seizure detection. Transcranial Doppler and near infrared spectroscopy were used for monitoring cerebral hemodynamic changes to detect early ischemia. Six studies reported cognitive outcomes ( n = 415) up to 12 months postdischarge and cognitive impairment (≥ one domain) was reported in 30%. CONCLUSIONS In-hospital neurologic complications are common in patients with sepsis. However, the mechanism and timing of those sepsis-associated complications are poorly understood and there are limited data on standardized neuromonitoring in this population.
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Affiliation(s)
- Tracey H Fan
- Department of Neurology, Neurocritical Care Division, Massachusetts General Hospital, Boston, MA
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Jacob Roberts
- School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Melissa Lydston
- Treadwell Virtual Library, Massachusetts General Hospital, Boston, MA
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - David Hager
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jose I. Suarez
- Divisions of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Denise Battaglini
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Sung-Min Cho
- Divisions of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
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Singh P, Verma A, Malshe N, Kallimath A, Oak G, Malviya M, Chouthai N, Suryawanshi P. Assessment of systemic circulation using ultrasound Doppler in late onset neonatal sepsis and its clinical correlation: an observational study. J Ultrasound 2023; 26:851-859. [PMID: 37728683 PMCID: PMC10632192 DOI: 10.1007/s40477-023-00826-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/10/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES To measure the Doppler velocimetry parameters in the anterior cerebral artery (ACA), superior mesenteric artery (SMA), and main renal artery (RA) in neonates with late-onset sepsis and correlate it with associated clinical morbidities. METHODOLOGY Prospective observational study carried out at a tertiary-level neonatal intensive care unit in India in 2022, enrolling 20 neonates with late-onset neonatal sepsis (LONS). Baseline characteristics and sepsis parameters obtained. Serial ultrasound performed on days 1, 3, and 7 from the day of clinical sepsis in the ACA, SMA, and RA and velocimetry measurements obtained. The findings were compared with 20 gestational age (GA) matched neonates in the control arm. RESULTS The mean GA of neonates with LONS was 31.03 ± 2.79 weeks and their mean birthweight was 1474 ± 509.99 g. The peak systolic velocity, resistive and pulsatility indices were significantly higher in ACA, SMA, and RA and the end-diastolic velocity was significantly lower in ACA and RA (P < 0.05) in LONS. The incidences of intraventricular hemorrhage (IVH), necrotising enterocolitis (NEC), and acute kidney injury (AKI) in neonates with LONS were 45%, 50%, and 10% respectively. A subgroup analysis of the Doppler velocimetry parameters in the neonates with LONS and for neonates with and without clinical outcomes did not suggest a significant difference. CONCLUSION LONS is associated with alterations in cerebral, splanchnic, and renal perfusion seen as abnormal blood flow velocimetry and vascular resistance which may predispose to IVH, NEC, and AKI.
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Affiliation(s)
- Pari Singh
- Department of Neonatology, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, 411043, India
| | - Arjun Verma
- Department of Neonatology, Mahatma Gandhi Medical College, Jaipur, India
| | - Nandini Malshe
- Department of Neonatology, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, 411043, India
| | - Aditya Kallimath
- Department of Neonatology, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, 411043, India
| | - Gauri Oak
- Department of Research, Bharati Vidyapeeth Deemed University Medical College, Pune, India
| | - Manoj Malviya
- Neonatology, Khoula Hospital, Ministry of Health, Muscat, Oman
| | | | - Pradeep Suryawanshi
- Department of Neonatology, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, 411043, India.
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3
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Luo H, Li G, Yang B, Huang X, Chen Y, Shen W. Association between the first 24 hours PaCO2 and all-cause mortality of patients suffering from sepsis-associated encephalopathy after ICU admission: A retrospective study. PLoS One 2023; 18:e0293256. [PMID: 37874838 PMCID: PMC10597528 DOI: 10.1371/journal.pone.0293256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/08/2023] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE The relationship between the levels of the first 24-h PaCO2 and the prognosis of sepsis-associated encephalopathy (SAE) remains unclear, and the first 24-h optimal target for PaCO2 is currently inconclusive. This study was performed to investigate the correlation between PaCO2 and all-cause mortality for SAE patients, establish a reference range of the initial 24-hour PaCO2 for clinicians in critical care, and explain the possible pathophysiological mechanisms of abnormal PaCO2 levels as a higher mortality risk factor for SAE. METHODS The baseline information and clinical data of patients were extracted from the fourth edition Medical Information Mart for Intensive Care database (MIMIC-IV 2.0). Multivariate logistic regressions were performed to assess the relationship between PaCO2 and all-cause mortality of SAE. Additionally, restricted cubic splines, Kaplan-Meier Survival analyses, propensity score matching (PSM) analyses, and subgroup analyses were conducted. RESULTS A total of 5471 patients were included in our cohort. In the original and matched cohort, multivariate logistic regression analysis showed that normocapnia and mild hypercapnia may be associated with a more favorable prognosis of SAE patients, and survival analysis supported the findings. In addition, a U-shaped association emerged when examining the initial 24-hour PaCO2 levels in relation to 30-day, 60-day, and 90-day mortality using restricted cubic splines, with an average cut-off value of 36.3mmHg (P for nonlinearity<0.05). Below the cut-off value, higher PaCO2 was associated with lower all-cause mortality, while above the cut-off value, higher PaCO2 was associated with higher all-cause mortality. Subsequent subgroup analyses revealed similar results for the subcohort of GCS≤8 compared to the original cohort. Additionally, when examining the subcohort of GCS>8, a L-shaped relationship between PaCO2 and the three clinical endpoints emerged, in contrast to the previously observed U-shaped pattern. The findings from the subcohort of GCS>8 suggested that patients experiencing hypocapnia had a more unfavorable prognosis, which aligns with the results obtained from corresponding multivariate logistic regression analyses. CONCLUSION The retrospective study revealed the association between the first 24-h PaCO2 and all-cause mortality risk (30-day, 60-day, and 90-day) for patients with SAE in ICU. The range (35mmHg-50mmHg) of PaCO2 may be the optimal target for patients with SAE in clinical practice.
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Affiliation(s)
- Honglian Luo
- Department of Neurology, Puai Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Wuhan Fourth Hospital, Wuhan, Hubei, China
| | - Gang Li
- Wuhan Fourth Hospital, Wuhan, Hubei, China
| | - Bingxin Yang
- Department of Neurology, Puai Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | | | - Yan Chen
- Wuhan Fourth Hospital, Wuhan, Hubei, China
| | - Wei Shen
- Department of Neurology, Puai Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Wuhan Fourth Hospital, Wuhan, Hubei, China
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4
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Dumbuya JS, Li S, Liang L, Zeng Q. Paediatric sepsis-associated encephalopathy (SAE): a comprehensive review. Mol Med 2023; 29:27. [PMID: 36823611 PMCID: PMC9951490 DOI: 10.1186/s10020-023-00621-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
Sepsis-associated encephalopathy (SAE) is one of the most common types of organ dysfunction without overt central nervous system (CNS) infection. It is associated with higher mortality, low quality of life, and long-term neurological sequelae, its mortality in patients diagnosed with sepsis, progressing to SAE, is 9% to 76%. The pathophysiology of SAE is still unknown, but its mechanisms are well elaborated, including oxidative stress, increased cytokines and proinflammatory factors levels, disturbances in the cerebral circulation, changes in blood-brain barrier permeability, injury to the brain's vascular endothelium, altered levels of neurotransmitters, changes in amino acid levels, dysfunction of cerebral microvascular cells, mitochondria dysfunction, activation of microglia and astrocytes, and neuronal death. The diagnosis of SAE involves excluding direct CNS infection or other types of encephalopathies, which might hinder its early detection and appropriate implementation of management protocols, especially in paediatric patients where only a few cases have been reported in the literature. The most commonly applied diagnostic tools include electroencephalography, neurological imaging, and biomarker detection. SAE treatment mainly focuses on managing underlying conditions and using antibiotics and supportive therapy. In contrast, sedative medication is used judiciously to treat those showing features such as agitation. The most widely used medication is dexmedetomidine which is neuroprotective by inhibiting neuronal apoptosis and reducing a sepsis-associated inflammatory response, resulting in improved short-term mortality and shorter time on a ventilator. Other agents, such as dexamethasone, melatonin, and magnesium, are also being explored in vivo and ex vivo with encouraging results. Managing modifiable factors associated with SAE is crucial in improving generalised neurological outcomes. From those mentioned above, there are still only a few experimentation models of paediatric SAE and its treatment strategies. Extrapolation of adult SAE models is challenging because of the evolving brain and technical complexity of the model being investigated. Here, we reviewed the current understanding of paediatric SAE, its pathophysiological mechanisms, diagnostic methods, therapeutic interventions, and potential emerging neuroprotective agents.
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Affiliation(s)
- John Sieh Dumbuya
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Siqi Li
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Lili Liang
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Qiyi Zeng
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, 510282, People's Republic of China.
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5
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Liu YX, Yu Y, Liu JP, Liu WJ, Cao Y, Yan RM, Yao YM. Neuroimmune Regulation in Sepsis-Associated Encephalopathy: The Interaction Between the Brain and Peripheral Immunity. Front Neurol 2022; 13:892480. [PMID: 35832175 PMCID: PMC9271799 DOI: 10.3389/fneur.2022.892480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/27/2022] [Indexed: 11/15/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE), the most popular cause of coma in the intensive care unit (ICU), is the diffuse cerebral damage caused by the septic challenge. SAE is closely related to high mortality and extended cognitive impairment in patients in septic shock. At present, many studies have demonstrated that SAE might be mainly associated with blood–brain barrier damage, abnormal neurotransmitter secretion, oxidative stress, and neuroimmune dysfunction. Nevertheless, the precise mechanism which initiates SAE and contributes to the long-term cognitive impairment remains largely unknown. Recently, a growing body of evidence has indicated that there is close crosstalk between SAE and peripheral immunity. The excessive migration of peripheral immune cells to the brain, the activation of glia, and resulting dysfunction of the central immune system are the main causes of septic nerve damage. This study reviews the update on the pathogenesis of septic encephalopathy, focusing on the over-activation of immune cells in the central nervous system (CNS) and the “neurocentral–endocrine–immune” networks in the development of SAE, aiming to further understand the potential mechanism of SAE and provide new targets for diagnosis and management of septic complications.
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Affiliation(s)
- Yu-xiao Liu
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Department of Neurosurgery, The Chinese PLA General Hospital, Beijing, China
| | - Yang Yu
- Department of Traditional Chinese Medical Science, Sixth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Jing-peng Liu
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Department of Traditional Chinese Medical Science, Sixth Medical Center of the Chinese PLA General Hospital, Beijing, China
| | - Wen-jia Liu
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences, Beijing Institute of Lifeomics, Beijing, China
| | - Yang Cao
- Department of Neurosurgery, The Chinese PLA General Hospital, Beijing, China
| | - Run-min Yan
- Department of Neurosurgery, The Chinese PLA General Hospital, Beijing, China
- *Correspondence: Yong-ming Yao
| | - Yong-ming Yao
- Translational Medicine Research Center, Medical Innovation Research Division and Fourth Medical Center of the Chinese PLA General Hospital, Beijing, China
- Run-min Yan
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6
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Battaglini D, Pelosi P, Robba C. The Importance of Neuromonitoring in Non Brain Injured Patients. Crit Care 2022; 26:78. [PMID: 35337357 PMCID: PMC8951660 DOI: 10.1186/s13054-022-03914-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. .,Department of Surgical Science and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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7
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Wood MD, Boyd JG, Wood N, Frank J, Girard TD, Ross-White A, Chopra A, Foster D, Griesdale DEG. The Use of Near-Infrared Spectroscopy and/or Transcranial Doppler as Non-Invasive Markers of Cerebral Perfusion in Adult Sepsis Patients With Delirium: A Systematic Review. J Intensive Care Med 2021; 37:408-422. [PMID: 33685273 PMCID: PMC8772019 DOI: 10.1177/0885066621997090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Several studies have previously reported the presence of altered cerebral perfusion during sepsis. However, the role of non-invasive neuromonitoring, and the impact of altered cerebral perfusion, in sepsis patients with delirium remains unclear. Methods: We performed a systematic review of studies that used near-infrared spectroscopy (NIRS) and/or transcranial Doppler (TCD) to assess adults (≥18 years) with sepsis and delirium. From study inception to July 28, 2020, we searched the following databases: Ovid MedLine, Embase, Cochrane Library, and Web of Science. Results: Of 1546 articles identified, 10 met our inclusion criteria. Although NIRS-derived regional cerebral oxygenation was consistently lower, this difference was only statistically significant in one study. TCD-derived cerebral blood flow velocity was inconsistent across studies. Importantly, both impaired cerebral autoregulation during sepsis and increased cerebrovascular resistance were associated with delirium during sepsis. However, the heterogeneity in NIRS and TCD devices, duration of recording (from 10 seconds to 72 hours), and delirium assessment methods (e.g., electronic medical records, confusion assessment method for the intensive care unit), precluded meta-analysis. Conclusion: The available literature demonstrates that cerebral perfusion disturbances may be associated with delirium in sepsis. However, future investigations will require consistent definitions of delirium, delirium assessment training, harmonized NIRS and TCD assessments (e.g., consistent measurement site and length of recording), as well as the quantification of secondary and tertiary variables (i.e., Cox, Mxa, MAPOPT), in order to fully assess the relationship between cerebral perfusion and delirium in patients with sepsis.
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Affiliation(s)
- Michael D Wood
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gordon Boyd
- Department of Critical Care Medicine, 4257Queen's University, Kingston, Ontario, Canada
| | - Nicole Wood
- Department of Physics, 8430University of Waterloo, Waterloo, Ontario, Canada
| | - James Frank
- Department of Physics, 7497Brock University, St. Catharines, Ontario, Canada
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Akash Chopra
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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8
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Mamontov OV, Sokolov AY, Volynsky MA, Osipchuk AV, Zaytsev VV, Romashko RV, Kamshilin AA. Animal model of assessing cerebrovascular functional reserve by imaging photoplethysmography. Sci Rep 2020; 10:19008. [PMID: 33149189 PMCID: PMC7642404 DOI: 10.1038/s41598-020-75824-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/16/2020] [Indexed: 01/12/2023] Open
Abstract
Assessment of the cerebral blood-flow-reserve in patients with cerebrovascular diseases is extremely important in terms of making prognosis, determining treatment tactics, and controlling the revascularization outcome in the case of reconstructive interventions on the brain vessels. However, there is no easy-to-use, contactless method for either assessing the functional reserve of the cortical vascular network or intraoperative monitoring of surgical intervention. Our study aims to demonstrate feasibility of green-light imaging photoplethysmography (iPPG) to estimate cerebrovascular functional reserve in animal model of craniosurgical intervention. Custom-made iPPG system was exploited to visualize intracranial vessels in anesthetized Wistar rats (n = 15). Video frames of rat's cortex were recorded concurrently with systemic blood pressure, end-tidal CO2, and electrocardiogram. We found that injection of dorzolamide (carbonic-anhydrase inhibitor) significantly increased the blood-pulsations amplitude in all animals by 35 ± 19% (p < 0.001). Such an increase negatively correlated with significant decrease in end-tidal CO2 by 32 ± 7% (p < 0.001). It is noteworthy that the dorzolamide injection did not lead to significant changes in systemic blood pressure. Concluding, pulsations amplitude is a marker of the vascular tone that can be used to evaluate the functional cerebrovascular reserve. Imaging PPG is a simple and convenient method to assess cerebral blood flow, including during various neurosurgical interventions.
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Affiliation(s)
- Oleg V Mamontov
- Department of Circulation Physiology, Almazov National Medical Research Centre, Saint Petersburg, Russia.,Department of Departmental Therapy, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Alexey Y Sokolov
- Department of Neuropharmacology, Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia.,Pavlov Institute of Physiology of the Russian Academy of Sciences, Saint Petersburg, Russia
| | - Maxim A Volynsky
- Faculty of Applied Optics, ITMO University, Saint Petersburg, Russia
| | - Anastasija V Osipchuk
- Department of Neuropharmacology, Valdman Institute of Pharmacology, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Valery V Zaytsev
- Faculty of Applied Optics, ITMO University, Saint Petersburg, Russia
| | - Roman V Romashko
- Laboratory of High-Precision Optical Measurements, Institute of Automation and Control Processes FEB RAS, Vladivostok, Russia
| | - Alexei A Kamshilin
- Laboratory of High-Precision Optical Measurements, Institute of Automation and Control Processes FEB RAS, Vladivostok, Russia. .,Faculty of Photonics and Optical Information, ITMO University, Saint Petersburg, Russia.
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9
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Sepsis-Associated Brain Dysfunction: A Review of Current Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165852. [PMID: 32806705 PMCID: PMC7460246 DOI: 10.3390/ijerph17165852] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 12/18/2022]
Abstract
Sepsis-associated brain dysfunction (SABD) may be the most common type of encephalopathy in critically ill patients. SABD develops in up to 70% of septic patients and represents the most frequent organ insufficiency associated with sepsis. It presents with a plethora of acute neurological features and may have several serious long-term psychiatric consequences. SABD might cause various pathological changes in the brain through numerous mechanisms. Clinical neurological examination is the basic screening method for SABD, although it may be challenging in subjects receiving with opioids and sedative agents. As electrographic seizures and periodic discharges might be present in 20% of septic patients, screening with electroencephalography (EEG) might be useful. Several imaging techniques have been suggested for non-invasive assessment of structure and function of the brain in SABD patients; however, their usefulness is rather limited. Although several experimental therapies have been postulated, at the moment, no specific treatment exists. Clinicians should focus on preventive measures and optimal management of sepsis. This review discusses epidemiology, clinical presentation, pathology, pathophysiology, diagnosis, management, and prevention of SABD.
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10
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Chenouard A, Toulgoat F, Rolland A, Liet JM, Maminirina P, Joram N, Bourgoin P. Right watershed cerebral infarction following neck cannulation for veno-arterial extracorporeal membrane oxygenation in pediatric septic shock: a case series. Perfusion 2020; 36:293-298. [PMID: 32755274 DOI: 10.1177/0267659120946724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Children supported by extracorporeal membrane oxygenation present a high risk of neurological complications. Although carotid cannulation is known to be associated with neurologic injury, conflicting data exist with regard to the predominance of right- or left-sided lesions. We describe here two infants requiring veno-arterial extracorporeal membrane oxygenation for septic shock who encountered right watershed infarction ipsilateral to carotid artery cannulation. Hemodynamic failure seems to be the most probable underlying mechanism. The asymmetry of transcranial Doppler metrics in one case and the low right regional cerebral oxygen saturation value observed soon after right cannulation in both cases suggest an insufficient cerebral collateral flow compensation. The risk of ipsilateral watershed injury should be considered before cervical cannulation, notably in the context of sepsis and an evaluation of the cerebral collateral blood flow before and just after cannulation may be interesting in order to identify infants with higher risk of ipsilateral ischemic lesions.
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Affiliation(s)
- Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | | | - Anne Rolland
- Department of Neurology, University Hospital, Nantes, France
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | | | - Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
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11
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Ratnaparkhi CR, Bayaskar MV, Dhok AP, Bhende V. Utility of Doppler ultrasound in early-onset neonatal sepsis. Indian J Radiol Imaging 2020; 30:52-58. [PMID: 32476750 PMCID: PMC7240890 DOI: 10.4103/ijri.ijri_265_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/26/2019] [Accepted: 12/17/2019] [Indexed: 11/06/2022] Open
Abstract
Background: Neonatal sepsis is an important cause of morbidity and mortality among newborns. As there is paucity of literature regarding early alteration of the cerebral blood flow (CBF) in neonatal sepsis our study aims to evaluate the changes in the CBF velocities and Doppler indices in neonates with early-onset neonatal sepsis (EONS) and to evaluate the predictive accuracy of cerebral blood flow velocities (CBFV) by using ultrasound Doppler as a diagnostic marker of EONS. Methods: This cross-sectional analytical study was conducted over a period of 2 years with 123 neonates enrolled in the study. The neonates were divided into two groups: Group I (with 54 neonates) - neonates with EONS and group II (with 69 neonates) - age-matched neonates without any signs of sepsis. Ultrasound Doppler examination was performed and the cerebral hemodynamics assessed in neonates during the first seventy two hours of life. Doppler indices and CBFV were measured in the internal carotid artery (ICA), middle cerebral artery (MCA), and vertebral artery (VA) of either side. Data were analyzed using the statistical program SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated at different selected cutoff values for CBFV parameters. Results: Lower resistance and higher peak systolic velocity and end diastolic velocity have been documented in neonates with EONS. Conclusion: Our study shows that the cerebral hemodynamics in neonates with EONS is altered which can be assessed bedside by noninvasive ultrasound Doppler examination.
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Affiliation(s)
- Chetana R Ratnaparkhi
- Department of Radiodiagnosis and Imaging, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Digdoh Hills, Hingna Road, Nagpur, Maharashtra, India
| | - Madhura V Bayaskar
- Department of Radiodiagnosis and Imaging, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Digdoh Hills, Hingna Road, Nagpur, Maharashtra, India
| | - Avinash P Dhok
- Department of Radiodiagnosis and Imaging, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Digdoh Hills, Hingna Road, Nagpur, Maharashtra, India
| | - Vikrant Bhende
- Department of Radiodiagnosis and Imaging, NKP Salve Institute of Medical Sciences and Research Centre and Lata Mangeshkar Hospital, Digdoh Hills, Hingna Road, Nagpur, Maharashtra, India
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Algebaly H, ElSherbini S, Galal A, Hamdi R, Baz A, Elbeleidy A. Transcranial Doppler Can Predict Development and Outcome of Sepsis-Associated Encephalopathy in Pediatrics With Severe Sepsis or Septic Shock. Front Pediatr 2020; 8:450. [PMID: 32974238 PMCID: PMC7468380 DOI: 10.3389/fped.2020.00450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 06/29/2020] [Indexed: 12/04/2022] Open
Abstract
Background and Aim: Sepsis is a common cause of pediatric intensive care unit (ICU) admission. Sepsis-associated encephalopathy (SAE) may occur owing to brain dysfunction in those patients and may be related to impaired cerebral microcirculation. Transcranial Doppler (TCD) can be used to detect this impairment. In this study, we aimed to assess the role of TCD in prediction of SAE and mortality in patients with severe sepsis or septic shock admitted to PICU. Patients and Methods: This prospective study included 75 children admitted to PICU owing to severe sepsis or septic shock. Upon admission, all patients were subjected to careful history taking, thorough clinical examination, and standard laboratory workup. Severity of clinical illness was assessed using the Pediatric Risk of Mortality (PRISM) III score. TCD was performed on the first day of admission after the normalization of systolic blood pressure with or without vasopressors. The primary study outcome was differences in the measurement of TCD in SAE, and the secondary outcome was discharge from ICU or mortality. Results: The study comprised 45 children with SAE and 30 age- and sex-matched children without SAE. In this study, SAE patients had significantly higher pulsatility index [PI; median interquartile range (IQR): 1.15 (0.98-1.48) vs. 1.0 (0.95-1.06), p = 0.002] and resistive index [RI; median (IQR): 0.68 (0.61-0.77) vs. 0.62 (0.59-0.64), p = 0.001] than had non-SAE patients. PI and RI showed good performance as predictors of subsequent SAE development [area under the curve (AUC): 0.72 and 0.73, respectively]. Non-survivors in SAE patients had significantly higher PRISM III. Receiver operating characteristic (ROC) curve analysis showed good performance of PI and RI as predictors of mortality at the end of follow-up. Conclusions: In children with SAE, cerebrovascular resistance is high and is associated with increased mortality.
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Affiliation(s)
- HebatAllah Algebaly
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Seham ElSherbini
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Ahmed Galal
- Pediatric Critical Care Unit, Children's Cancer Hospital, Cairo University, Cairo, Egypt
| | - Rania Hamdi
- Pediatric Imaging Unit, Department of Radiology, Cairo University, Cairo, Egypt
| | - Ahmed Baz
- Pediatric Imaging Unit, Department of Radiology, Cairo University, Cairo, Egypt
| | - Ahmed Elbeleidy
- Pediatric Critical Care Unit, Department of Pediatrics, Cairo University, Cairo, Egypt
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13
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Guo ZN, Jin H, Sun H, Zhao Y, Liu J, Ma H, Sun X, Yang Y. Antioxidant Melatonin: Potential Functions in Improving Cerebral Autoregulation After Subarachnoid Hemorrhage. Front Physiol 2018; 9:1146. [PMID: 30174621 PMCID: PMC6108098 DOI: 10.3389/fphys.2018.01146] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/30/2018] [Indexed: 12/30/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a subtype of stroke with high mortality and morbidity. Impaired cerebral autoregulation following SAH has been reported owing to effects on sympathetic control, endothelial function, myogenic response, and cerebral metabolism. Impaired cerebral autoregulation is associated with early brain injury, cerebral vasospasm/delayed cerebral ischemia, and SAH prognosis. However, few drugs have been reported to improve cerebral autoregulation after SAH. Melatonin is a powerful antioxidant that is effective (easily crosses the blood brain barrier) and safe (tolerated in large doses without toxicity). Theoretically, melatonin may impact the control mechanisms of cerebral autoregulation via antioxidative effects, protection of endothelial cell integrity, suppression of sympathetic nerve activity, increase in nitric oxide bioavailability, mediation of the myogenic response, and amelioration of hypoxemia. Furthermore, melatonin may have a comprehensive effect on cerebral autoregulation. This review discusses the potential effects of melatonin on cerebral autoregulation following SAH, in terms of the association between pharmacological activities and the mechanisms of cerebral autoregulation.
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Affiliation(s)
- Zhen-Ni Guo
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hang Jin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Huijie Sun
- Cadre Ward, The First Hospital of Jilin University, Changchun, China
| | - Yingkai Zhao
- Cadre Ward, The First Hospital of Jilin University, Changchun, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hongyin Ma
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xin Sun
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China
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14
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Le Dorze M, Huché F, Coelembier C, Rabuel C, Payen D. Impact of fluid challenge increase in cardiac output on the relationship between systemic and cerebral hemodynamics in severe sepsis compared to brain injury and controls. Ann Intensive Care 2018; 8:74. [PMID: 29956057 PMCID: PMC6023801 DOI: 10.1186/s13613-018-0419-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022] Open
Abstract
Background Cognitive dysfunction and delirium after ICU are frequent and may partially result from brain ischemia episodes. We hypothesized that systemic inflammation (severe sepsis or septic shock) modifies the control of brain circulation and the relation between systemic and cerebral hemodynamic after a positive response to fluid challenge (FC). Methods Three groups of patients were studied if they increased stroke volume (SV) > 10% after 250 or 500 ml of crystalloids: control group: patients free of comorbidity anesthetized for orthopedic surgery; sepsis group: patients with severe sepsis or septic shock (classic definition); brain injury (BI) group: trauma brain jury or hemorrhagic stroke with no detectable systemic inflammation. The measurements before and after FC were mean arterial blood pressure (MAP) (radial catheter); SV and cardiac output (CO; transesophageal Doppler); bilateral middle cerebral artery (MCAv) velocity with peak systolic (PSV) and end diastolic (EDV) values (transcranial Doppler); end-tidal CO2. The role of MAP increase was investigated by an arbitrarily threshold increase of 5%, called responder in CO and MAP (RR). The remaining patients were call responders in CO and non-responders in MAP (RnR). Nonparametric tests were used for statistical analysis. Results Among the 86 screened patients, 66 have completed the protocol: 17 in control group; 38 in sepsis group; and 11 in BI group. All patients increased SV > 10% after FC. Only the sepsis group increased MAP [+ 12 (2–25%), p < 0.05] with a significant increase in PSV and EDV [(17 (3–30)% and 17 (12–42)%, respectively (p < 0.05)], which did not change in the two other groups. The septic RR or RnR had similar variations in MCAv after FC. The baseline MAP < or > baseline median MAP had similar MCAv. Conclusions After a FC-induced increase in SV, MCAv (PSV and EDV) increased only in septic group, mostly independently from MAP increase and from baseline MAP level. Cerebral perfusion becomes passively dependent on systemic blood flow, suggesting a modification of the control of cerebrovascular tone in sepsis-induced systemic inflammation. This information has been considered in the clinical management of septic patients. Electronic supplementary material The online version of this article (10.1186/s13613-018-0419-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Florian Huché
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Clément Coelembier
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Christophe Rabuel
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Didier Payen
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, APHP, 2 Rue Ambroise Paré, 75010, Paris, France. .,UMR INSERM 1160, University Paris 7 Denis Diderot, Paris, France.
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15
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Vasopressors Do Not Influence Cerebral Critical Closing Pressure During Systemic Inflammation Evoked by Experimental Endotoxemia and Sepsis in Humans. Shock 2018; 49:529-535. [DOI: 10.1097/shk.0000000000001003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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16
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Molnár L, Németh N, Berhés M, Hajdú E, Papp L, Molnár Á, Szabó J, Deák Á, Fülesdi B. Assessment of cerebral circulation in a porcine model of intravenously given E. coli induced fulminant sepsis. BMC Anesthesiol 2017; 17:98. [PMID: 28738837 PMCID: PMC5525280 DOI: 10.1186/s12871-017-0389-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 07/12/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of the present work was to assess cerebral hemodynamic changes in a porcine model of E.coli induced fulminant sepsis. METHODS Nineteen healthy female Hungahib pigs, 10-12 weeks old, randomly assigned into two groups: Control (n = 9) or Septic Group (n = 10). In the Sepsis group Escherichia coli culture suspended in physiological saline was intravenously administrated in a continuously increasing manner according to the following protocol: 2 ml of bacterial culture suspended in physiological saline was injected in the first 30 min, then 4 ml of bacterial culture was administered within 30 min, followed by infusion of 32 ml bacterial culture for 2 h. Control animals received identical amount of saline infusion. Systemic hemodynamic parameters were assessed by PiCCo monitoring, and cerebral hemodynamics by transcranial Doppler sonography (transorbital approach) in both groups. RESULTS In control animals, systemic hemodynamic variables and cerebral blood flow velocities and pulsatility indices were relatively stable during the entire procedure. In septic animals shock developed in 165 (IQR: 60-255) minutes after starting the injection of E.coli solution. Blood pressure values gradully decreased, whereas pulse rate increased. A decrease in cardiac index, an increased systemic vascular resistance, and an increased stroke volume variation were observed. Mean cerebral blood flow velocity in the middle cerebral artery did not change during the procedure, but pulsatility index significantly increased. CONCLUSIONS There is vasoconstriction at the level of the cerebral arterioles in the early phase of experimental sepsis that overwhelmes autoregulatory response. These results may serve as additional pathophysiological information on the cerebral hemodynamic changes occurring during the septic process and may contribute to a better understanding of the pathomechanism of septic encephalopathy.
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Affiliation(s)
- Levente Molnár
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Norbert Németh
- Department of Operative Techniques and Surgical Research, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Mariann Berhés
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Endre Hajdú
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Lóránd Papp
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary
| | - Ábel Molnár
- Department of Operative Techniques and Surgical Research, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Judit Szabó
- Department of Medical Microbiology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Ádám Deák
- Department of Operative Techniques and Surgical Research, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Faculty of Medicine, Nagyerdei krt. 98, Debrecen, H 4032, Hungary. .,Outcomes Research Consortium, Cleveland, USA.
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17
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Abstract
Over the past decades, the incidence of sepsis and resultant neurologic sequelae has increased, both in industrialized and low- or middle-income countries, by approximately 5% per year. Up to 300 patients per 100 000 population per year are reported to suffer from sepsis, severe sepsis, and septic shock. Mortality is up to 30%, depending on the precision of diagnostic criteria. The increasing incidence of sepsis is partially explained by demographic changes in society, with aging, increasing numbers of immunocompromised patients, dissemination of multiresistant pathogens, and greater availability of supportive medical care in both industrialized and middle-income countries. This results in more septic patients being admitted to intensive care units. Septic encephalopathy is a manifestation especially of severe sepsis and septic shock where the neurologist plays a crucial role in diagnosis and management. It is well known that timely treatment of sepsis improves outcome and that septic encephalopathy may precede other signs and symptoms. Particularly in the elderly and immunocompromised patient, the brain may be the first organ to show signs of failure. The neurologist diagnosing early septic encephalopathy may therefore contribute to the optimal management of septic patients. The brain is not only an organ failing in sepsis (a "sepsis victim" - as with other organs), but it also overwhelmingly influences all inflammatory processes on a variety of pathophysiologic levels, thus contributing to the initiation and propagation of septic processes. Therefore, the best possible pathophysiologic understanding of septic encephalopathy is essential for its management, and the earliest possible therapy is crucial to prevent the evolution of septic encephalopathy, brain failure, and poor prognosis.
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Affiliation(s)
- E Schmutzhard
- Neurocritical Care Unit, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
| | - B Pfausler
- Neurocritical Care Unit, Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
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18
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Transcranial Doppler evaluation of cerebral hemodynamic alteration in preterms with early onset neonatal sepsis. Artery Res 2017. [DOI: 10.1016/j.artres.2017.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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19
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de Azevedo DS, Salinet ASM, de Lima Oliveira M, Teixeira MJ, Bor-Seng-Shu E, de Carvalho Nogueira R. Cerebral hemodynamics in sepsis assessed by transcranial Doppler: a systematic review and meta-analysis. J Clin Monit Comput 2016; 31:1123-1132. [PMID: 27757739 DOI: 10.1007/s10877-016-9945-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/11/2016] [Indexed: 12/14/2022]
Abstract
Cerebral microcirculation is gradually compromised during sepsis, with significant reductions in the function of capillaries and blood perfusion in small vessels. Transcranial Doppler ultrasound (TCD) has been used to assess cerebral circulation in a typical clinical setting. This study was to systematically review TCD studies, assess their methodological quality, and identify trends that can be associated with the temporal evolution of sepsis and its clinical outcome. A meta-analysis of systematic reviews was conducted according to the PRISMA statement. Articles were searched from 1982 until the conclusion of this review in December 2015. Twelve prospective and observational studies were selected. Evaluations of cerebral blood flow, cerebral autoregulation, and carbon dioxide (CO2) vasoreactivity were summarized. A temporal pattern of the evolution of the illness was found. In early sepsis, the median blood flow velocity (Vm) and pulsatility index (PI) increased, and the cerebral autoregulation (CA) remained unchanged. In contrast, Vm normalization, PI reduction and CA impairment were found in later sepsis (patients with severe sepsis or septic shock). Cerebral haemodynamic is impaired in sepsis. Modifications in cerebral blood flow may be consequence to the endothelial dysfunction of the microvasculature induced by the release of inflammatory mediators. A better understanding of cerebral hemodynamics may improve the clinical management of patients with sepsis and, consequently, improve clinical outcomes.
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Affiliation(s)
- Daniel Silva de Azevedo
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Angela Salomao Macedo Salinet
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Marcelo de Lima Oliveira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Manoel Jacobsen Teixeira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil.
| | - Ricardo de Carvalho Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, Avenida Doutor Arnaldo, 455, Cerqueira César, São Paulo, SP, CEP 01246-904, Brazil
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20
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The Severity of Cecal Ligature and Puncture-Induced Sepsis Correlates with the Degree of Encephalopathy, but the Sepsis Does Not Lead to Acute Activation of Spleen Lymphocytes in Mice. Mol Neurobiol 2015; 53:3389-3399. [DOI: 10.1007/s12035-015-9290-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 06/04/2015] [Indexed: 09/29/2022]
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21
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Zenaide PV, Gusmao-Flores D. Biomarkers in septic encephalopathy: a systematic review of clinical studies. Rev Bras Ter Intensiva 2015; 25:56-62. [PMID: 23887761 PMCID: PMC4031860 DOI: 10.1590/s0103-507x2013000100011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/20/2013] [Indexed: 01/06/2023] Open
Abstract
Objective The aim of this study was to systematically review the importance of
neuron-specific enolase and S100 beta for diagnosing and monitoring septic
encephalopathy. Methods A PubMed database search was performed to identify studies that evaluated S100
beta and neuron-specific enolase serum levels in patients with sepsis and that
were published between January 2000 and April 2012. Only human studies that
employed an additional method of neurological assessment were selected. Results Nine studies were identified, seven of which associated high concentrations of
S100 beta and neuron-specific enolase with the development of septic
encephalopathy. Four studies also associated these concentrations with increased
mortality. However, two studies did not find such an association when they
evaluated S100 beta levels, and one of these studies did not observe a correlation
between neuron-specific enolase and septic encephalopathy. Conclusion S100 beta and neuron-specific enolase are promising biomarkers for diagnosing and
monitoring patients with septic encephalopathy, but more research is
necessary.
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Affiliation(s)
- Paula Veriato Zenaide
- Academic Medical Course, Escola Bahiana de Medicina e Saúde Pública - Salvador, Brazil.
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23
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Basu S, Dewangan S, Barman S, Anupurba S, Shukla RC, Kumar A. Cerebral blood flow velocity in asymptomatic premature neonates exposed to clinical chorioamnionitis. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2014. [DOI: 10.1016/j.cegh.2013.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Pierrakos C, Attou R, Decorte L, Kolyviras A, Malinverni S, Gottignies P, Devriendt J, De Bels D. Transcranial Doppler to assess sepsis-associated encephalopathy in critically ill patients. BMC Anesthesiol 2014; 14:45. [PMID: 24944522 PMCID: PMC4061318 DOI: 10.1186/1471-2253-14-45] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/03/2014] [Indexed: 01/08/2023] Open
Abstract
Background Transcranial Doppler can detect cerebral perfusion alteration in septic patients. We correlate static Transcranial Doppler findings with clinical signs of sepsis-associated encephalopathy. Methods Forty septic patients were examined with Transcranial Doppler on the first and third day of sepsis diagnosis. The pulsatility index (PI) and cerebral blood flow index (CBFi) were calculated by blood velocity in the middle cerebral artery (cm/sec). Patients underwent a daily cognitive assessment with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test. Results Twenty-one patients (55%) were found to present confusion. The majority of the patients presented a PI > 1.1 (76%). PI on the first day (but not the third day) could predict a positive CAM-ICU test in septic patients (PI cut-off: 1.3, AUC: 0.905, p < 0.01, sensitivity: 95%, specificity: 88%, AUC: 0.618, p = 0.24). Multivariable analysis showed that PI on the first day is related to a positive CAM-ICU test independent of age and APACHE II score (OR: 5.6, 95% CI: 1.1-29, p = 0.03). A decrease of the PI on the third day was observed in the group that presented initially high PI (>1.3) (2.2 ± 0.71 vs. 1.81 ± 0.64; p = 0.02). On the other hand, an increase in PI was observed in the other patients (1.01 ± 0.15 vs. 1.58 ± 0.57; p < 0.01). On only the first day, the mean blood velocity in the middle cerebral artery and CBFi were found to be lower in those patients with a high initial PI (36 ± 21 vs. 62 ± 28 cm/sec; p < 0.01, 328 ± 101 vs. 581 ± 108; p < 0.01, respectively). Conclusions Cerebral perfusion disturbance observed with Transcranial Doppler could explain clinical symptoms of sepsis-associated encephalopathy.
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Affiliation(s)
- Charalampos Pierrakos
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
| | - Rachid Attou
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
| | - Laurence Decorte
- Departments of Geriatrics, Brugmann University Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Athanasios Kolyviras
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
| | - Stefano Malinverni
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
| | - Philippe Gottignies
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
| | - Jacques Devriendt
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
| | - David De Bels
- Departments of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Place Van Gehuchten 4, 1020 Bruxelles, Belgium
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Dal-Pizzol F, Tomasi CD, Ritter C. Septic encephalopathy: does inflammation drive the brain crazy? REVISTA BRASILEIRA DE PSIQUIATRIA 2014; 36:251-8. [DOI: 10.1590/1516-4446-2013-1233] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/11/2013] [Indexed: 11/21/2022]
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Abstract
Every year, more cases of sepsis appear in intensive care units. The most frequent complication of sepsis is septic encephalopathy (SE), which is also the essential determinant of mortality. Despite many years of research, it still is not known at which stage of sepsis the first signs of SE appear; however, it is considered the most frequent form of encephalopathy. Patients have dysfunction of cognitive abilities and consciousness, and sometimes even epileptic seizures. Despite intensive treatment, the effects of SE remain for many years and constitute an important social problem. Numerous studies indicate that changes in the brain involve free radicals, nitric oxide, increased synthesis of inflammatory factors, disturbances in cerebral circulation, microthromboses, and ischemia, which cause considerable neuronal destruction in different areas of the brain. To determine at what point during sepsis the first signs of SE appear, different experimental models are needed to detect the aforementioned changes and to select the proper therapy for this syndrome.
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Affiliation(s)
- Marek Ziaja
- Department of Histology, Jagiellonian University Medical College, Kraków, Poland.
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Pierrakos C, Antoine A, Velissaris D, Michaux I, Bulpa P, Evrard P, Ossemann M, Dive A. Transcranial doppler assessment of cerebral perfusion in critically ill septic patients: a pilot study. Ann Intensive Care 2013; 3:28. [PMID: 23965228 PMCID: PMC3765692 DOI: 10.1186/2110-5820-3-28] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 08/08/2013] [Indexed: 01/02/2023] Open
Abstract
Background The aim of this study is to evaluate the feasibility and efficacy of Transcranial Doppler (TCD) in assessing cerebral perfusion changes in septic patients. Methods Using TCD, we measured the mean velocity in the middle cerebral artery (VmMCA, cm/sec) and calculated the pulsatility index (PI), resistance index (RI) and cerebral blood flow index (CBFi = 10*MAP/1.47PI) on the first day of patients’ admission or on the first day of sepsis development; measurements were repeated on the second day. Sepsis was defined according to standard criteria. Results Forty-one patients without any known neurologic deficit treated in our 24-bed Critical Care Unit were assessed (Sepsis Group = 20, Control Group = 21). Examination was feasible in 91% of septic and 85% of non-septic patients (p = 0.89). No difference was found between the two groups in mean age, mean arterial pressure (MAP) or APACHE II score. The pCO2 values were higher in septic patients (46 ± 12 vs. 39 ± 4 mmHg p < 0.01). No statistically significant higher values of VmMCA were found in septic patients (110 ± 34 cm/sec vs. 99 ± 28 cm/sec p = 0.17). Higher values of PI and RI were found in septic patients (1.15 ± 0.25 vs. 0.98 ± 0.16 p < 0.01, 0.64 ± 0.08 vs. 0.59 ± 0.06 p < 0.01, respectively). No statistically significant lower values of CBFi were found in septic patients (497 ± 116 vs. 548 ± 110 p = 0.06). Conclusions Our results suggest cerebral vasoconstriction in septic compared to non-septic patients. TCD is an efficient and feasible exam to evaluate changes in cerebral perfusion during sepsis.
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Affiliation(s)
- Charalampos Pierrakos
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Aurélie Antoine
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, University Hospital of Patras, Patras Rio 26504, Greece
| | - Isabelle Michaux
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Pierre Bulpa
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Patrick Evrard
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Michel Ossemann
- Department of Neurology, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
| | - Alain Dive
- Department of Intensive Care, Université Catholique de Louvain, Mont-Godinne University Hospital, Avenue Docteur G., Thérasse 1, Yvoir 5530, Belgium
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Role of nicotine on cognitive and behavioral deficits in sepsis-surviving rats. Brain Res 2013; 1507:74-82. [DOI: 10.1016/j.brainres.2013.02.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 02/19/2013] [Accepted: 02/20/2013] [Indexed: 12/11/2022]
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Rosengarten B, Krekel D, Kuhnert S, Schulz R. Early neurovascular uncoupling in the brain during community acquired pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R64. [PMID: 22520083 PMCID: PMC3681393 DOI: 10.1186/cc11310] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/28/2012] [Accepted: 04/20/2012] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Sepsis leads to microcirculatory dysfunction and therefore a disturbed neurovascular coupling in the brain. To investigate if the dysfunction is also present in less severe inflammatory diseases we studied the neurovascular coupling in patients suffering from community acquired pneumonia. METHODS Patients were investigated in the acute phase of pneumonia and after recovery. The neurovascular coupling was investigated with a simultaneous electroencephalogram (EEG)-Doppler technique applying a visual stimulation paradigm. Resting EEG frequencies, visual evoked potentials as well as resting and stimulated hemodynamic responses were obtained. Disease severity was characterized by laboratory and cognitive parameters as well as related scoring systems. Data were compared to a control group. RESULTS Whereas visually evoked potentials (VEP) remained stable a significant slowing and therefore uncoupling of the hemodynamic responses were found in the acute phase of pneumonia (Rate time: control group: 3.6 ± 2.5 vs. acute pneumonia: 1.6 ± 2.4 s; P < 0.0005). In the initial investigation, patients who deteriorated showed a decreased hemodynamic response as compared with those who recovered (gain: recovered: 15% ± 4% vs. deteriorated: 9% ± 3%, P < 0.05; control: 14% ± 5%). After recovery the coupling normalized. CONCLUSIONS Our study underlines the role of an early microcirculatory dysfunction in inflammatory syndromes that become evident in pre-septic conditions with a gradual decline according to disease severity.
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Affiliation(s)
- Bernhard Rosengarten
- Department of Neurology, Justus-Liebig University of Giessen, Klinikstrasse 33, 35392 Giessen, Germany.
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Schramm P, Klein KU, Falkenberg L, Berres M, Closhen D, Werhahn KJ, David M, Werner C, Engelhard K. Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsis-associated delirium. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R181. [PMID: 23036135 PMCID: PMC3682283 DOI: 10.1186/cc11665] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 10/04/2012] [Indexed: 11/10/2022]
Abstract
Introduction Sepsis-associated delirium (SAD) increases morbidity in septic patients and, therefore, factors contributing to SAD should be further characterized. One possible mechanism might be the impairment of cerebrovascular autoregulation (AR) by sepsis, leading to cerebral hypo- or hyperperfusion in these haemodynamically unstable patients. Therefore, the present study investigates the relationship between the incidence of SAD and the status of AR during sepsis. Methods Cerebral blood flow velocity was measured using transcranial Doppler sonography and was correlated with the invasive arterial blood pressure curve to calculate the index of AR Mx (Mx>0.3 indicates impaired AR). Mx was measured daily during the first 4 days of sepsis. Diagnosis of a SAD was performed using the confusion assessment method for ICU (CAM-ICU) and, furthermore the predominant brain electrical activity in electroencephalogram (EEG) both at day 4 after reduction of sedation to RASS >-2. Results 30 critically ill adult patients with severe sepsis or septic shock (APACHE II 32 ± 6) were included. AR was impaired at day 1 in 60%, day 2 in 59%, day 3 in 41% and day 4 in 46% of patients; SAD detected by CAM-ICU was present in 76 % of patients. Impaired AR at day 1 was associated with the incidence of SAD at day 4 (p = 0.035). Conclusions AR is impaired in the great majority of patients with severe sepsis during the first two days. Impaired AR is associated with SAD, suggesting that dysfunction of AR is one of the trigger mechanisms contributing to the development of SAD. Trial registration clinicalTrials.gov ID NCT01029080
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Endotoxemia reduces cerebral perfusion but enhances dynamic cerebrovascular autoregulation at reduced arterial carbon dioxide tension. Crit Care Med 2012; 40:1873-8. [PMID: 22610190 DOI: 10.1097/ccm.0b013e3182474ca7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The administration of endotoxin to healthy humans reduces cerebral blood flow but its influence on dynamic cerebral autoregulation remains unknown. We considered that a reduction in arterial carbon dioxide tension would attenuate cerebral perfusion and improve dynamic cerebral autoregulation in healthy subjects exposed to endotoxemia. DESIGN Prospective descriptive study. SETTING Hospital research laboratory. SUBJECTS Ten healthy young subjects (age: 32 ± 8 yrs [mean ± SD]; weight: 84 ± 10 kg; weight: 184 ± 5 cm; body mass index: 25 ± 2 kg/m2) participated in the study. INTERVENTIONS Systemic hemodynamics, middle cerebral artery mean flow velocity, and dynamic cerebral autoregulation evaluated by transfer function analysis in the very low (<0.07 Hz), low (0.07-0.15 Hz), and high (>0.15 Hz) frequency ranges were monitored in these volunteers before and after an endotoxin bolus (2 ng/kg; Escherichia coli). MEASUREMENTS AND MAIN RESULTS Endotoxin increased body temperature of the subjects from 36.8 ± 0.4°C to 38.6 ± 0.5°C (p < .001) and plasma tumor necrosis factor-α from 5.6 (2.8-6.7) pg/mL to 392 (128-2258) pg/mL (p < .02). Endotoxemia had no influence on mean arterial pressure (95 [74-103] mm Hg vs. 92 [78-104] mm Hg; p = .75), but increased cardiac output (8.3 [6.1-9.5] L·min(-1) vs. 6.0 [4.5-8.2] L·min(-1); p = .02) through an elevation in heart rate (82 ± 9 beats·min(-1) vs. 63 ± 10 beats·min(-1); p < .001), whereas arterial carbon dioxide tension (37 ± 5 mm Hg vs. 41 ± 2 mm Hg; p < .05) and middle cerebral artery mean flow velocity (37 ± 9 cm·sec(-1) vs. 47 ± 10 cm·sec(-1); p < .01) were reduced. In regard to dynamic cerebral autoregulation, endotoxemia was associated with lower middle cerebral artery mean flow velocity variability (1.0 ± 1.0 [cm·sec(-1)] Hz vs. 2.8 ± 1.5 [cm·sec(-1)] Hz; p < .001), reduced gain (0.52 ± 0.11 cm·sec(-1) x mm Hg(-1) vs. 0.74 ± 0.17 cm·sec(-1) x mm Hg(-1); p < .05), normalized gain (0.22 ± 0.05 vs. 0.40 ± 0.17%·%; p < .05), and higher mean arterial pressure-to-middle cerebral artery mean flow velocity phase difference (p < .05) in the low frequency range (0.07-0.15 Hz). CONCLUSIONS These data support that the reduction in arterial carbon dioxide tension explains the improved dynamic cerebral autoregulation and the reduced cerebral perfusion encountered in healthy subjects during endotoxemia.
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Cerebral blood flow velocity in early-onset neonatal sepsis and its clinical significance. Eur J Pediatr 2012; 171:901-9. [PMID: 22215129 DOI: 10.1007/s00431-011-1643-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 11/29/2011] [Indexed: 10/14/2022]
Abstract
Chorioamnionitis is a known risk factor for neurological damage in newborns. The present study aimed at assessing the changes in cerebral blood flow velocity (CBFV) in early-onset neonatal sepsis (EONS) and determining its predictive value as well as prognostic significance. Inborn neonates with antenatal risk factors for chorioamnionitis were followed up for development of EONS, diagnosed by presence of clinical signs along with positive blood culture and/or elevated interleukin-6 (IL-6) concentrations (≥50 pg/mL) in umbilical cord blood. Comparison group was formed by asymptomatic neonates who had risk factors for chorioamnionitis but did not develop EONS and cord blood IL-6 concentrations were <50 pg/mL. CBFV (resistance and pulsatility indices, peak systolic flow velocity, and vascular diameter) of internal carotid, vertebral, and middle cerebral arteries was assessed by transcranial Doppler ultrasonography within 24 h of birth. The babies were kept under clinical and radiological follow-up for a minimum period of 6 months. Data were analyzed by SPSS 16.0. Final study group contained 55 neonates with sepsis and 35 asymptomatic control neonates. Blood culture was positive in 27 babies of the sepsis group with a preponderance of Gram-negative bacterial isolation. Significantly lower resistance, vasodilatation, and higher blood flow were noted in all the cerebral arteries of the sepsis group. Increase in CBFV was correlated with elevated IL-6 concentrations. CBFV parameters showed significant predictive accuracy as early diagnostic markers of EONS. Among the sepsis group, 14 patients showed signs of intracranial hemorrhage during the hospital stay of which four expired and six showed signs of ventricular dilatation during follow-up. These patients had significantly higher CBFV compared to those who survived. Assessment of CBFV at early hours of birth can be adopted as an additional bedside, non-invasive investigation with immediate diagnostic and late prognostic significance.
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Cerebral autoregulation in the first day after preterm birth: no evidence of association with systemic inflammation. Pediatr Res 2012; 71:253-60. [PMID: 22278187 DOI: 10.1038/pr.2011.46] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Both systemic inflammation and impaired cerebral autoregulation (CA) have been associated with brain injury in preterm infants. We hypothesized that impaired CA represents a hemodynamic link between inflammation and brain injury. RESULTS Neither fetal vasculitis nor interleukin-6 (IL-6) affected CA significantly. A high level of IL-6 was associated with hypotension (P = 0.03) irrespective of dopamine therapy. The magnitude of impairment in CA increased with decreasing mean arterial blood pressure (MAP) (P = 0.02). No significant associations were found between these parameters and either intraventricular hemorrhage (IVH) (n = 10) or neonatal mortality (n = 8). DISCUSSION In conclusion, postnatal inflammation was weakly associated with arterial hypotension, and hypotension was weakly associated with impaired autoregulation. There was no direct association, however, between autoregulation and antenatal or postnatal signs of inflammation. METHODS In our study, 60 infants (mean (±SD) of gestational age (GA) 27 (±1.3) wk) underwent continuous recording of MAP and cerebral oxygenation index (OI) by means of near-infrared spectroscopy (NIRS) for 2.3 ± 0.5 h, starting 18 ± 9 h after birth. Coherence and transfer function gain between MAP and OI represented the presence and degree of impairment of CA, respectively. We considered fetal vasculitis (placenta histology) to be an antenatal marker of inflammation, and used the level of IL-6 in blood, measured at 18 ± 10 h after birth, as a postnatal marker of inflammation. Definition of hypotension was MAP (mm Hg) ≤ GA (wk).
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Sepsis-associated encephalopathy. Transl Med UniSa 2012; 2:20-7. [PMID: 23905041 PMCID: PMC3728775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Sepsis-associated encephalopathy (SAE) is defined as a diffuse or multifocal cerebral dysfunction induced by the systemic response to the infection without clinical or laboratory evidence of direct brain infection. Its pathogenesis is multifactorial. SAE generally occurs early during severe sepsis and precedes multiple-organ failure. The most common clinical feature of SAE is the consciousness alteration which ranges from mildly reduced awareness to unresponsiveness and coma. Diagnosis of SAE is primarily clinical and depends on the exclusion of other possible causes of brain deterioration. Electroencephalography (EEG) is almost sensitive, but it is not specific for SAE. Computed Tomography (CT) head scan generally is negative in case of SAE, while Magnetic Resonance Imaging (MRI) can show brain abnormalities in case of SAE, but they are not specific for this condition. Somatosensitive Evoked Potentials (SEPs) are sensitive markers of developing cerebral dysfunction in sepsis. Cerebrospinal fluid (CBF) analysis is generally normal, a part an inconstant elevation of proteins concentration. S100B and NSE have been proposed like biomarkers for diagnosis of SAE, but the existing data are controversial. SAE is reversible even if survivors of severe sepsis have often long lasting or irreversible cognitive and behavioral sequel; however the presence of SAE can have a negative influence on survival. A specific therapy of SAE does not exist and the outcome depends on a prompt and appropriate treatment of sepsis as whole.
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Fülesdi B, Szatmári S, Antek C, Fülep Z, Sárkány P, Csiba L, Molnár C. Cerebral vasoreactivity to acetazolamide is not impaired in patients with severe sepsis. J Crit Care 2012; 27:337-43. [PMID: 22227080 DOI: 10.1016/j.jcrc.2011.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 10/29/2011] [Accepted: 11/03/2011] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The pathophysiology of sepsis-associated encephalopathy (SAE) is not entirely clear, but one of the possible underlying mechanisms is the alteration of the cerebral microvascular function. The aim of the present work was to test whether cerebral vasomotor reactivity is impaired in patients with severe sepsis. METHODS Patients fulfilling the criteria of clinical sepsis and showing at least 2 organ dysfunctions were included (n = 16). Nonseptic healthy persons without previous diseases affecting cerebral vasoreactivity served as controls (n = 16). Transcranial Doppler blood flow velocities were measured at rest and at 5, 10, 15, and 20 minutes after intravenous administration of 15 mg/kg acetazolamide. The time course of the acetazolamide effect on cerebral blood flow velocity (cerebrovascular reactivity [CVR]) and the maximal vasodilatory effect of acetazolemide (cerebrovascular reserve capacity [CRC]) were compared among the groups. RESULTS Absolute blood flow velocities after administration of the vasodilator drug did not differ between control and septic patients. Assessment of the time course of the vasomotor reaction showed that patients with sepsis reacted in a similar fashion to the vasodilatory stimulus than control persons. When assessing the maximal vasodilatory ability of the cerebral arterioles to acetazolamide during vasomotor testing, we found that there was no difference in vasodilatory ability between septic and healthy subjects (CRC controls, 54.8% ± 11.1%; CRC sepsis-associated encephalopathy, 61.1% ± 34.4%; P = .49). CONCLUSIONS We conclude that cerebrovascular reactivity is not impaired in patients with severe sepsis. It is conceivable that cerebral vasoreactivity may be differently involved at different severity stages of the septic process.
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Affiliation(s)
- Béla Fülesdi
- Department of Anaesthesiology and Intensive Care, Neurology, University of Debrecen, Health and Medical Science Centre, Debrecen, Hungary.
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Abstract
In 2010 Critical Care published a large number of articles on critical care aspects of neurologic and neurosurgical conditions. These aspects included investigation of diagnostic criteria for bacterial meningitis, critical illness myopathy and their relationship to systemic inflammation. A number of studies investigated the biology of sepsis-related delirium, its biomarkers, its relationship to inflammation and its impact on outcome. Other teams reported on the use of magnetic resonance imaging, biomarkers and electroencephalogram to predict outcome in patients who were comatose following cardiac arrest. Our understanding of the pathophysiology as well as management of subarachnoid hemorrhage was addressed in several papers. Topics included the effect of hemodynamic treatment of delayed cerebral ischemia, pulmonary edema and the impact of subarachnoid hemorrhage on endocrine function. Finally, outcome from neurocritical care and patients' retrospective willingness to consent to the treatment they received were reported.
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Affiliation(s)
- Michael T Scalfani
- Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, Campus Box 8111, 660 S, Euclid Avenue, St Louis, MO 63110, USA
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Avtan SM, Kaya M, Orhan N, Arslan A, Arican N, Toklu AS, Gürses C, Elmas I, Kucuk M, Ahishali B. The effects of hyperbaric oxygen therapy on blood–brain barrier permeability in septic rats. Brain Res 2011; 1412:63-72. [DOI: 10.1016/j.brainres.2011.07.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 07/07/2011] [Accepted: 07/07/2011] [Indexed: 01/11/2023]
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Yang Y, Zhang P, Lv R, He Q, Zhu Y, Yang X, Chen J. Mitochondrial DNA haplogroup R in the Han population and recovery from septic encephalopathy. Intensive Care Med 2011; 37:1613-9. [PMID: 21847652 DOI: 10.1007/s00134-011-2319-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 04/12/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine whether the main mitochondrial DNA (mtDNA) haplogroups of the Han people are associated with neurological recovery from septic encephalopathy. METHODS We studied 137 individuals with septic encephalopathy who were sequentially admitted to the intensive care unit or the emergency intensive care unit at the First Affiliated Hospital, College of Medicine, Zhejiang University, and the People's Hospital of Zhejiang Province. Demographic and clinical data were recorded along with clinical outcome over 28 days. The Glasgow coma scale (GCS) score was calculated daily until it reached 15 or until the patient died during the 28-day period. Follow-up was completed for all study participants. We then determined the mtDNA haplogroups of the patients by analyzing sequences of hypervariable mtDNA segments and testing diagnostic polymorphisms in the mtDNA coding region with DNA probes. RESULTS MtDNA haplogroup R, one of the main mtDNA haplogroups of the Han people, was a strong independent predictor of outcome following septic encephalopathy, conferring a 4.053-fold (95% CI 1.803-9.110, p = 0.001) increased chance of neurological recovery within 28 days compared with those with a non-R mtDNA haplogroup. CONCLUSION In the Han population, mtDNA haplogroup R is a strong independent predictor of the outcome of septic encephalopathy, conferring an increased chance of neurological recovery compared with individuals with a non-R haplogroup. Our results provide potential insights into the mechanisms involved in septic encephalopathy, and reveal that the mtDNA haplogroup R is an independent predictor of the outcome of septic encephalopathy.
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Affiliation(s)
- Yi Yang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China.
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Imamura Y, Wang H, Matsumoto N, Muroya T, Shimazaki J, Ogura H, Shimazu T. Interleukin-1β causes long-term potentiation deficiency in a mouse model of septic encephalopathy. Neuroscience 2011; 187:63-9. [PMID: 21571042 DOI: 10.1016/j.neuroscience.2011.04.063] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 04/27/2011] [Accepted: 04/28/2011] [Indexed: 01/18/2023]
Abstract
Sepsis induces multiple organ dysfunction syndrome including septic encephalopathy (SE), which results in cognitive impairment. However, an effective treatment for SE remains unknown. We determined the role of interleukin-1β (IL-1β) in long-term potentiation (LTP) deficiency after SE. At first, endotoxin level in the blood was increased at 24 h after cecum ligation and puncture (CLP) (i.e. SE model). Second, the expression of IL-1β and its receptor in the hippocampus was determined by immunohistochemistry and immunoblotting. The number of Iba1-positive cells and their expression of IL-1β were enhanced by CLP with disruption of the blood brain barrier. Also, Iba1, IL-1β, and occludin protein expressions were consistent with immunohistochemical results. Third, we used an electrophysiological technique and observed the LTP deficiency, a hallmark of learning and memory, in the slices of hippocampus after CLP. Since type 1 interleukin-1 receptors (IL-1R1s) on neuronal cells were increased in the hippocampus, we utilized IL-1R1 antagonist. Pre-incubation with IL-1R1 antagonist for 30 min before recording of field excitatory post-synaptic potentials (fEPSPs) in the hippocampus canceled LTP deficiency after CLP. These results suggest the novel importance of IL-1β in synaptic plasticity deficiency associated with sepsis-induced brain inflammation. In a mouse model of SE, IL-1R1 inhibition is important in protecting synaptic function of the hippocampus after induction of SE.
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Affiliation(s)
- Y Imamura
- Department of Trauma and Acute Critical Care Center, Osaka University Hospital, Osaka, Japan.
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Szatmári S, Fülep Z, Sárkány P, Antek C, Siró P, Molnár C, Fülesdi B. Cerebral vasoreactivity is not impaired in patients with severe sepsis. Crit Care 2011. [PMCID: PMC3066993 DOI: 10.1186/cc9739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Szatmári S, Végh T, Antek C, Takács I, Síró P, Fülesdi B. Sepsis-associated encephalopathy. Orv Hetil 2010; 151:1340-6. [DOI: 10.1556/oh.2010.28932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A szepszishez társuló encephalopathia a szisztémás gyulladásos reakció korai szakaszában jelentkező, gyakori, de klinikai szempontból elhanyagolt tünete. A szisztémás szepszis okozta diffúz agyi működészavar, újabb elnevezés szerint a szepszishez társuló encephalopathia (sepsis-associated encephalopathy – SAE) változatos megjelenésű lehet: az átmeneti, reverzíbilis encephalopathiával jellemezhető formától egészen a visszafordíthatatlan agyi károsodással járó súlyos formáig terjedhet a klinikai spektrum. A jelen közleményben a hazai és a nemzetközi szakirodalom áttekintése alapján össze kívántuk foglalni a kórkép kórélettani hátterét, a leggyakrabban előforduló klinikai tüneteket és a kezelés lehetséges módjait. Fel kívántuk hívni a figyelmet arra, hogy szepszisben a különböző súlyosságú tudatzavar az egyik legkorábbi figyelmeztető tünet, ezért a szepszis szempontjából veszélyeztetett betegekben felismerése nagy klinikai jelentőségű.
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Affiliation(s)
- Szilárd Szatmári
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Tamás Végh
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Csaba Antek
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - István Takács
- 2 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Sebészeti Intézet Debrecen
| | - Péter Síró
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
| | - Béla Fülesdi
- 1 Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Aneszteziológiai és Intenzív Terápiás Tanszék Debrecen Móricz Zs. krt. 22. 4032
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