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Bird JD, MacLeod DB, Griesdale DE, Sekhon MS, Hoiland RL. Shining a light on cerebral autoregulation: Are we anywhere near the truth? J Cereb Blood Flow Metab 2024:271678X241245488. [PMID: 38603610 DOI: 10.1177/0271678x241245488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
The near-infrared spectroscopy (NIRS)-derived cerebral oximetry index (COx) has become popularized for non-invasive neuromonitoring of cerebrovascular function in post-cardiac arrest patients with hypoxic-ischemic brain injury (HIBI). We provide commentary on the physiologic underpinnings and assumptions of NIRS and the COx, potential confounds in the context of HIBI, and the implications for the assessment of cerebral autoregulation.
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Affiliation(s)
- Jordan D Bird
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - David B MacLeod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada
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2
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Hirsch KG, Tamura T, Ristagno G, Sekhon MS. Wolf Creek XVII Part 8: Neuroprotection. Resusc Plus 2024; 17:100556. [PMID: 38328750 PMCID: PMC10847936 DOI: 10.1016/j.resplu.2024.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Introduction Post-cardiac arrest brain injury (PCABI) is the primary determinant of clinical outcomes for patients who achieve return of spontaneous circulation after cardiac arrest (CA). There are limited neuroprotective therapies available to mitigate the acute pathophysiology of PCABI. Methods Neuroprotection was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation, and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. Results Top 5 knowledge gaps included developing therapies for neuroprotection; improving understanding of the pathophysiology, mechanisms, and natural history of PCABI; deploying precision medicine approaches; optimizing resuscitation and CPR quality; and determining optimal timing for and duration of interventions. Top 5 barriers to translation included patient heterogeneity; nihilism & lack of knowledge about cardiac arrest; challenges with the translational pipeline; absence of mechanistic biomarkers; and inaccurate neuro-triage and neuroprognostication. Top 5 research priorities focused on translational research and trial optimization; addressing patient heterogeneity and individualized interventions; improving understanding of pathophysiology and mechanisms; developing mechanistic and outcome biomarkers across post-CA time course; and improving implementation of science and technology. Conclusion This overview can serve as a guide to transform the care and outcome of patients with PCABI. Addressing these topics has the potential to improve both research and clinical care in the field of neuroprotection for PCABI.
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Affiliation(s)
- Karen G. Hirsch
- Department of Neurology, Stanford University, Stanford, CA, United States
| | - Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mypinder S. Sekhon
- Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, Canada
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Ye SC, Cheung CC, Lauder E, Grunau B, Moghaddam N, van Diepen S, Holmes DT, Sekhon MS, Christenson J, Tallon JM, Fordyce CB. Association of admission serum sodium and outcomes following out-of-hospital cardiac arrest. Am Heart J 2024; 268:29-36. [PMID: 37992794 DOI: 10.1016/j.ahj.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND The prognostic association between dysnatremia and outcomes in out-of-hospital cardiac arrest (OHCA) is not well understood. Given hypernatremia is associated with poor outcomes in critical illness and hyponatremia may exacerbate cerebral edema, we hypothesized that dysnatremia on OHCA hospital admission would be associated with worse neurological outcomes. METHODS We studied adults (≥19 years) with non-traumatic OHCA between 2009 and 2016 who were enrolled in the British Columbia Cardiac Arrest Registry and survived to hospital admission at 2 quaternary urban hospitals. We stratified cases by admission serum sodium into hyponatremic (<135 mmol/L), normonatremic (135-145 mmol/L), and hypernatremic (>145 mmol/L) groups. We used logistic regression models, adjusted for age, sex, shockable rhythm, admission serum lactate, and witnessed arrest, to estimate the association between admission sodium and favorable neurological outcome (cerebral performance category 1-2 or modified Rankin scale 0-3). RESULTS Of 414 included patients, 63 were hyponatremic, 330 normonatremic, and 21 hypernatremic. In each respective group, 21 (33.3%), 159 (48.2%), and 3 (14.3%) experienced good neurological outcomes. In univariable models, hyponatremia (OR 0.53, 95% CI 0.30-0.93) and hypernatremia (OR 0.19, 95% CI 0.05-0.65) were associated with lower odds of good neurological outcomes compared to the normonatremia group. After adjustment, only hypernatremia was associated with lower odds of good neurological outcomes (OR 0.22, 95% CI 0.05-0.98). CONCLUSIONS Hypernatremia at admission was independently associated with decreased probability of good neurological outcomes at discharge post-OHCA. Future studies should focus on elucidating the pathophysiology of dysnatremia following OHCA.
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Affiliation(s)
- Si Cong Ye
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher C Cheung
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erik Lauder
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Grunau
- BC Resuscitation Research Collaborative, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Emergency Health Services, Vancouver, British Columbia, Canada
| | - Nima Moghaddam
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- BC Resuscitation Research Collaborative, British Columbia, Canada; Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel T Holmes
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mypinder S Sekhon
- BC Resuscitation Research Collaborative, British Columbia, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jim Christenson
- BC Resuscitation Research Collaborative, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John M Tallon
- BC Resuscitation Research Collaborative, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Emergency Health Services, Vancouver, British Columbia, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Resuscitation Research Collaborative, British Columbia, Canada; Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.
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Patel NA, Bhattal HS, Griesdale DE, Hoiland RL, Sekhon MS. Impact of Skin Pigmentation on Cerebral Regional Saturation of Oxygen Using Near-Infrared Spectroscopy: A Systematic Review. Crit Care Explor 2024; 6:e1049. [PMID: 38352943 PMCID: PMC10863935 DOI: 10.1097/cce.0000000000001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES Near-infrared spectroscopy (NIRS) is used in critical care settings to measure regional cerebral tissue oxygenation (rSo2). However, the accuracy of such measurements has been questioned in darker-skinned individuals due to the confounding effects of light absorption by melanin. In this systematic review, we aim to synthesize the available evidence on the effect of skin pigmentation on rSo2 readings. DATA SOURCES We systematically searched MEDLINE, Cochrane Database of Systematic Reviews, Embase, and Google Scholar from inception to July 1, 2023. STUDY SELECTION In compliance with our PROSPERO registration (CRD42022347548), we selected articles comparing rSo2 measurements in adults either between racial groups or at different levels of skin pigmentation. Two independent reviewers conducted full-text reviews of all potentially relevant articles. DATA EXTRACTION We extracted data on self-reported race or level of skin pigmentation and mean rSo2 values. DATA SYNTHESIS Of the 11,495 unique records screened, two studies (n = 7,549) met our inclusion criteria for systematic review. Sun et al (2015) yielded significantly lower rSo2 values for African Americans compared with Caucasians, whereas Stannard et al (2021) found little difference between self-reported racial groups. This discrepancy is likely because Stannard et al (2021) used a NIRS platform which specifically purports to control for the effects of melanin. Several other studies that did not meet our inclusion criteria corroborated the notion that skin pigmentation results in lower rSo2 readings. CONCLUSIONS Skin pigmentation likely results in attenuated rSo2 readings. However, the magnitude of this effect may depend on the specific NIRS platform used.
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Affiliation(s)
- Nikunj A Patel
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Harvir S Bhattal
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for Researching Brain Ischemia, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for Researching Brain Ischemia, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, Canada
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Parikh K, Shepley BR, Tymko MM, Hijmans JG, Hoiland RL, Desouza CA, Sekhon MS, Ainslie PN, Bain AR. Cerebral uptake of microvesicles occurs in normocapnic but not hypocapnic passive hyperthermia in young healthy male adults. J Physiol 2023; 601:5601-5616. [PMID: 37975212 DOI: 10.1113/jp285265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023] Open
Abstract
Passive hyperthermia causes cerebral hypoperfusion primarily from heat-induced respiratory alkalosis. However, despite the cerebral hypoperfusion, it is possible that the mild alkalosis might help to attenuate cerebral inflammation. In this study, the cerebral exchange of extracellular vesicles (microvesicles), which are known to elicit pro-inflammatory responses when released in conditions of stress, were examined in hyperthermia with and without respiratory alkalosis. Ten healthy male adults were heated passively, using a warm water-perfused suit, up to core temperature + 2°C. Blood samples were taken from the radial artery and internal jugular bulb. Microvesicle concentrations were determined in platelet-poor plasma via cells expressing CD62E (activated endothelial cells), CD31+ /CD42b- (apoptotic endothelial cells), CD14 (monocytes) and CD45 (pan-leucocytes). Cerebral blood flow was measured via duplex ultrasound of the internal carotid and vertebral arteries to determine cerebral exchange kinetics. From baseline to poikilocapnic (alkalotic) hyperthermia, there was no change in microvesicle concentration from any cell origin measured (P-values all >0.05). However, when blood CO2 tension was normalized to baseline levels in hyperthermia, there was a marked increase in cerebral uptake of microvesicles expressing CD62E (P = 0.028), CD31+ /CD42b- (P = 0.003) and CD14 (P = 0.031) compared with baseline, corresponding to large increases in arterial but not jugular venous concentrations. In a subset of seven participants who underwent hypercapnia and hypocapnia in the absence of heating, there was no change in microvesicle concentrations or cerebral exchange, suggesting that hyperthermia potentiated the CO2 /pH-mediated cerebral uptake of microvesicles. These data provide insight into a potential beneficial role of respiratory alkalosis in heat stress. KEY POINTS: The hyperthermia-induced hyperventilatory response is observed in most humans, despite causing potentially harmful reductions in cerebral blood flow. We tested the hypothesis that the respiratory-induced alkalosis is associated with lower circulating microvesicle concentrations, specifically in the brain, despite the reductions in blood flow. At core temperature + 2°C with respiratory alkalosis, microvesicles derived from endothelial cells, monocytes and leucocytes were at concentrations similar to baseline in the arterial and cerebral venous circulation, with no changes in cross-brain microvesicle kinetics. However, when core temperature was increased by 2°C with CO2 /pH normalized to resting levels, there was a marked cerebral uptake of microvesicles derived from endothelial cells and monocytes. The CO2 /pH-mediated alteration in cerebral microvesicle uptake occurred only in hyperthermia. These new findings suggest that the heat-induced hyperventilatory response might serve a beneficial role by preventing potentially inflammatory microvesicle uptake in the brain.
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Affiliation(s)
- Khushali Parikh
- Faculty of Human Kinetics, Department of Kinesiology, University of Windsor, Windsor, ON, Canada
| | - Brooke R Shepley
- Faculty of Human Kinetics, Department of Kinesiology, University of Windsor, Windsor, ON, Canada
| | - Michael M Tymko
- Centre for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada
- Department of Human Health and Nutritional Sciences, College of Biological Science, University of Guelph, Guelph, ON, Canada
| | - Jamie G Hijmans
- Department of Integrative Biology, University of Colorado Boulder, Boulder, CO, USA
| | - Ryan L Hoiland
- Centre for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for Researching Brain Ischemia, University of British Columbia, Vancouver, BC, Canada
| | | | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for Researching Brain Ischemia, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada
| | - Anthony R Bain
- Faculty of Human Kinetics, Department of Kinesiology, University of Windsor, Windsor, ON, Canada
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Thiara S, Sekhon MS. Blood pressure augmentation after cardiac arrest: Time to move beyond manipulating vital signs. Resuscitation 2023; 190:109913. [PMID: 37516157 DOI: 10.1016/j.resuscitation.2023.109913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Sharanjit Thiara
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada; International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada; Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.
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7
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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8
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Hoiland RL, Robba C, Menon DK, Citerio G, Sandroni C, Sekhon MS. Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest. Intensive Care Med 2023; 49:1062-1078. [PMID: 37507572 PMCID: PMC10499700 DOI: 10.1007/s00134-023-07165-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
The cerebral oxygen cascade includes three key stages: (a) convective oxygen delivery representing the bulk flow of oxygen to the cerebral vascular bed; (b) diffusion of oxygen from the blood into brain tissue; and (c) cellular utilisation of oxygen for aerobic metabolism. All three stages may become dysfunctional after resuscitation from cardiac arrest and contribute to hypoxic-ischaemic brain injury (HIBI). Improving convective cerebral oxygen delivery by optimising cerebral blood flow has been widely investigated as a strategy to mitigate HIBI. However, clinical trials aimed at optimising convective oxygen delivery have yielded neutral results. Advances in the understanding of HIBI pathophysiology suggest that impairments in the stages of the oxygen cascade pertaining to oxygen diffusion and cellular utilisation of oxygen should also be considered in identifying therapeutic strategies for the clinical management of HIBI patients. Culprit mechanisms for these impairments may include a widening of the diffusion barrier due to peri-vascular oedema and mitochondrial dysfunction. An integrated approach encompassing both intra-parenchymal and non-invasive neuromonitoring techniques may aid in detecting pathophysiologic changes in the oxygen cascade and enable patient-specific management aimed at reducing the severity of HIBI.
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Affiliation(s)
- Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada.
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Hoiland RL, MacLeod DB, Stacey BS, Caldwell HG, Howe CA, Nowak-Flück D, Carr JMJR, Tymko MM, Coombs GB, Patrician A, Tremblay JC, Van Mierlo M, Gasho C, Stembridge M, Sekhon MS, Bailey DM, Ainslie PN. Hemoglobin and cerebral hypoxic vasodilation in humans: Evidence for nitric oxide-dependent and S-nitrosothiol mediated signal transduction. J Cereb Blood Flow Metab 2023; 43:1519-1531. [PMID: 37042194 PMCID: PMC10414015 DOI: 10.1177/0271678x231169579] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 01/20/2023] [Accepted: 03/10/2023] [Indexed: 04/13/2023]
Abstract
Cerebral hypoxic vasodilation is poorly understood in humans, which undermines the development of therapeutics to optimize cerebral oxygen delivery. Across four investigations (total n = 195) we investigated the role of nitric oxide (NO) and hemoglobin-based S-nitrosothiol (RSNO) and nitrite (NO 2 - ) signaling in the regulation of cerebral hypoxic vasodilation. We conducted hemodilution (n = 10) and NO synthase inhibition experiments (n = 11) as well as hemoglobin oxygen desaturation protocols, wherein we measured cerebral blood flow (CBF), intra-arterial blood pressure, and in subsets of participants trans-cerebral release/uptake of RSNO and NO 2 - . Higher CBF during hypoxia was associated with greater trans-cerebral RSNO release but not NO 2 - , while NO synthase inhibition reduced cerebral hypoxic vasodilation. Hemodilution increased the magnitude of cerebral hypoxic vasodilation following acute hemodilution, while in 134 participants tested under normal conditions, hypoxic cerebral vasodilation was inversely correlated to arterial hemoglobin concentration. These studies were replicated in a sample of polycythemic high-altitude native Andeans suffering from excessive erythrocytosis (n = 40), where cerebral hypoxic vasodilation was inversely correlated to hemoglobin concentration, and improved with hemodilution (n = 6). Collectively, our data indicate that cerebral hypoxic vasodilation is partially NO-dependent, associated with trans-cerebral RSNO release, and place hemoglobin-based NO signaling as a central mechanism of cerebral hypoxic vasodilation in humans.
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Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - David B MacLeod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Hannah G Caldwell
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Connor A Howe
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Daniela Nowak-Flück
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Jay MJR Carr
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Michael M Tymko
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Geoff B Coombs
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Alexander Patrician
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Joshua C Tremblay
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Michelle Van Mierlo
- Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
| | - Chris Gasho
- Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Mike Stembridge
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Mypinder S Sekhon
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Philip N Ainslie
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
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10
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Sekhon MS, Stukas S, Hirsch-Reinshagen V, Thiara S, Schoenthal T, Tymko M, McNagny KM, Wellington C, Hoiland R. Neuroinflammation and the immune system in hypoxic ischaemic brain injury pathophysiology after cardiac arrest. J Physiol 2023. [PMID: 37639379 DOI: 10.1113/jp284588] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Hypoxic ischaemic brain injury after resuscitation from cardiac arrest is associated with dismal clinical outcomes. To date, most clinical interventions have been geared towards the restoration of cerebral oxygen delivery after resuscitation; however, outcomes in clinical trials are disappointing. Therefore, alternative disease mechanism(s) are likely to be at play, of which the response of the innate immune system to sterile injured tissue in vivo after reperfusion has garnered significant interest. The innate immune system is composed of three pillars: (i) cytokines and signalling molecules; (ii) leucocyte migration and activation; and (iii) the complement cascade. In animal models of hypoxic ischaemic brain injury, pro-inflammatory cytokines are central to propagation of the response of the innate immune system to cerebral ischaemia-reperfusion. In particular, interleukin-1 beta and downstream signalling can result in direct neural injury that culminates in cell death, termed pyroptosis. Leucocyte chemotaxis and activation are central to the in vivo response to cerebral ischaemia-reperfusion. Both parenchymal microglial activation and possible infiltration of peripherally circulating monocytes might account for exacerbation of an immunopathological response in humans. Finally, activation of the complement cascade intersects with multiple aspects of the innate immune response by facilitating leucocyte activation, further cytokine release and endothelial activation. To date, large studies of immunomodulatory therapies have not been conducted; however, lessons learned from historical studies using therapeutic hypothermia in humans suggest that quelling an immunopathological response might be efficacious. Future work should delineate the precise pathways involved in vivo in humans to target specific signalling molecules.
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Veronica Hirsch-Reinshagen
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Michael Tymko
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
| | - Kelly M McNagny
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Biomedical Research Centre, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl Wellington
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
- International Centre for Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching BRain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
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11
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Rikhraj KJK, Ronsley C, Sekhon MS, Mitra AR, Griesdale DEG. High-normal versus low-normal mean arterial pressure thresholds in critically ill patients: a systematic review and meta-analysis of randomized trials. Can J Anaesth 2023; 70:1244-1254. [PMID: 37268800 DOI: 10.1007/s12630-023-02494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 06/04/2023] Open
Abstract
PURPOSE Targeted blood pressure thresholds remain unclear in critically ill patients. Two prior systematic reviews have not shown differences in mortality with a high mean arterial pressure (MAP) threshold, but there have been new studies published since. Thus, we conducted an updated systematic review and meta-analysis of randomized controlled trials (RCTs) that compared the effect of a high-normal vs low-normal MAP on mortality, favourable neurologic outcome, need for renal replacement therapy, and adverse vasopressor-induced events in critically ill patients. SOURCE We searched six databases from inception until 1 October 2022 for RCTs of critically ill patients targeted to either a high-normal vs a low-normal MAP threshold for at least 24 hr. We assessed study quality using the revised Cochrane risk-of-bias 2 tool and the risk ratio (RR) was used as the summary measure of association. We used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence. PRINCIPAL FINDINGS We included eight RCTs with 4,561 patients. Four trials were conducted in patients following out-of-hospital cardiac arrest, two in patients with distributive shock requiring vasopressors, one in patients with septic shock, and one in patients with hepatorenal syndrome. The pooled RRs for mortality (eight RCTs; 4,439 patients) and favourable neurologic outcome (four RCTs; 1,065 patients) were 1.06 (95% confidence interval [CI], 0.99 to 1.14; moderate certainty) and 0.99 (95% CI, 0.90 to 1.08; moderate certainty), respectively. The RR for the need for renal replacement therapy (four RCTs; 4,071 patients) was 0.97 (95% CI, 0.87 to 1.08; moderate certainty). There was no statistical between-study heterogeneity across all outcomes. CONCLUSION This updated systematic review and meta-analysis of RCTs found no differences in mortality, favourable neurologic outcome, or the need for renal replacement therapy between critically ill patients assigned to a high-normal vs low-normal MAP target. STUDY REGISTRATION PROSPERO (CRD42022307601); registered 28 February 2022.
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Affiliation(s)
- Kiran J K Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada.
- Department of Emergency Medicine, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Claire Ronsley
- Department of Emergency Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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12
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Shemie SD, Wilson LC, Hornby L, Basmaji J, Baker AJ, Bensimon CM, Chandler JA, Chassé M, Dawson R, Dhanani S, Mooney OT, Sarti AJ, Simpson C, Teitelbaum J, Torrance S, Boyd JG, Brennan J, Brewster H, Carignan R, Dawe KJ, Doig CJ, Elliott-Pohl K, Gofton TE, Hartwick M, Healey A, Honarmand K, Hornby K, Isac G, Kanji A, Kawchuk J, Klowak JA, Kramer AH, Kromm J, LeBlanc AE, Lee-Ameduri K, Lee LA, Leeies M, Lewis A, Manara A, Matheson S, McKinnon NKA, Murphy N, Briard JN, Pope TM, Sekhon MS, Shanker JJS, Singh G, Singh J, Slessarev M, Soliman K, Sutherland S, Weiss MJ, Shaul RZ, Zuckier LS, Zorko DJ, Rochwerg B. A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline. Can J Anaesth 2023; 70:483-557. [PMID: 37131020 PMCID: PMC10203028 DOI: 10.1007/s12630-023-02431-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 05/04/2023] Open
Abstract
This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.
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Affiliation(s)
- Sam D Shemie
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
- McGill University, Montreal, QC, Canada.
- MUHC Research Institute, Montreal, QC, Canada.
- Canadian Blood Services, Ottawa, ON, Canada.
| | | | | | | | - Andrew J Baker
- Unity Health Toronto, Toronto, ON, Canada
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Sonny Dhanani
- University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Owen T Mooney
- University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Gift of Life Program, Winnipeg, MB, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
| | - Aimee J Sarti
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christy Simpson
- Canadian Blood Services, Ottawa, ON, Canada
- Dalhousie University, Halifax, NS, Canada
| | - Jeanne Teitelbaum
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- McGill University, Montreal, QC, Canada
| | | | - J Gordon Boyd
- Kingston General Hospital, Kingston, ON, Canada
- Queen's University, Kingston, ON, Canada
| | | | | | | | - Kirk J Dawe
- Eastern Health, St. John's, NL, Canada
- Memorial University of Newfoundland, St. John's, NL, Canada
| | - Christopher J Doig
- University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | | | | | - Michael Hartwick
- University of Ottawa, Ottawa, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- McMaster University, Hamilton, ON, Canada
- William Osler Health System, Brampton, ON, Canada
| | - Kimia Honarmand
- Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
| | | | - George Isac
- University of British Columbia, Vancouver, BC, Canada
| | - Aly Kanji
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- McGill University, Montreal, QC, Canada
| | - Joann Kawchuk
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | | | - Andreas H Kramer
- University of Calgary, Calgary, AB, Canada
- Southern Alberta Organ & Tissue Donation Program, Calgary, AB, Canada
| | - Julie Kromm
- University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | - Allana E LeBlanc
- University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health, Vancouver, BC, Canada
- Canadian Association of Critical Care Nurses, London, ON, Canada
| | - Katarina Lee-Ameduri
- University of Manitoba, Winnipeg, MB, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
| | - Laurie A Lee
- University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital, Calgary, AB, Canada
| | - Murdoch Leeies
- University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Gift of Life Program, Winnipeg, MB, Canada
- Canadian Critical Care Society, Markham, ON, Canada
| | - Ariane Lewis
- NYU Langone Medical Center, New York City, NY, USA
| | | | | | - Nicole K A McKinnon
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
- Peter Gilgan Center for Research and Learning, Toronto, ON, Canada
| | | | | | - Thaddeus M Pope
- University of Ottawa, Ottawa, ON, Canada
- Mitchell Hamline School of Law, Saint Paul, MN, USA
- Queensland University of Technology, Brisbane, Qld, Australia
- Albany Medical College, Albany, NY, USA
- University of Minnesota Center for Bioethics, Minneapolis, MN, USA
| | - Mypinder S Sekhon
- University of British Columbia, Vancouver, BC, Canada
- Vancouver General Hospital, Vancouver, BC, Canada
| | | | - Gurmeet Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Singh
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Marat Slessarev
- Western University, London, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Karim Soliman
- Queen's University, Kingston, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Lakeridge Health, Oshawa, ON, Canada
| | | | - Matthew J Weiss
- Transplant Québec, Montreal, QC, Canada
- CHU de Québec - Université Laval, Quebec City, QC, Canada
- Université Laval, Quebec City, QC, Canada
| | - Randi Zlotnik Shaul
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Lionel S Zuckier
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - David J Zorko
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Bram Rochwerg
- McMaster University, Hamilton, ON, Canada
- Canadian Critical Care Society, Markham, ON, Canada
- Canadian Critical Care Trials Group, Markham, ON, Canada
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Cooper JG, Stukas SK, Grey R, Ghodsi M, Ahmed N, Hoiland R, Thiara S, Foster D, Harper M, Panenka WJ, Silverberg NN, Stoessl JA, Sossi V, Sekhon MS, Wellington CL. The Utility of Blood Based Biomarkers in Detecting Neurological Complications of COVID‐19 in Critically Ill Patients. Alzheimers Dement 2022. [DOI: 10.1002/alz.069086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Rebecca Grey
- University of British Columbia Vancouver BC Canada
| | | | - Nyra Ahmed
- University of British Columbia Vancouver BC Canada
| | - Ryan Hoiland
- University of British Columbia Vancouver BC Canada
| | - Sonny Thiara
- University of British Columbia Vancouver BC Canada
| | | | - Megan Harper
- University of British Columbia Vancouver BC Canada
| | | | | | | | - Vesna Sossi
- Physics and Astronomy Department and DM Center for Brain Health, University of British Columbia Vancouver BC Canada
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14
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Messing M, Sekhon MS, Hughes MR, Stukas S, Hoiland RL, Cooper J, Ahmed N, Hamer MS, Li Y, Shin SB, Tung LW, Wellington CL, Sin DD, Leslie KB, McNagny KM. Prognostic peripheral blood biomarkers at ICU admission predict COVID-19 clinical outcomes. Front Immunol 2022; 13:1010216. [DOI: 10.3389/fimmu.2022.1010216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022] Open
Abstract
The COVID-19 pandemic continues to challenge the capacities of hospital ICUs which currently lack the ability to identify prospectively those patients who may require extended management. In this study of 90 ICU COVID-19 patients, we evaluated serum levels of four cytokines (IL-1β, IL-6, IL-10 and TNFα) as well as standard clinical and laboratory measurements. On 42 of these patients (binned into Initial and Replication Cohorts), we further performed CyTOF-based deep immunophenotyping of peripheral blood mononuclear cells with a panel of 38 antibodies. All measurements and patient samples were taken at time of ICU admission and retrospectively linked to patient clinical outcomes through statistical approaches. These analyses resulted in the definition of a new measure of patient clinical outcome: patients who will recover after short ICU stays (< 6 days) and those who will subsequently die or recover after long ICU stays (≥6 days). Based on these clinical outcome categories, we identified blood prognostic biomarkers that, at time of ICU admission, prospectively distinguish, with 91% sensitivity and 91% specificity (positive likelihood ratio 10.1), patients in the two clinical outcome groups. This is achieved through a tiered evaluation of serum IL-10 and targeted immunophenotyping of monocyte subsets, specifically, CD11clow classical monocytes. Both immune biomarkers were consistently elevated ( ≥15 pg/ml and ≥2.7 x107/L for serum IL-10 and CD11clow classical monocytes, respectively) in those patients who will subsequently die or recover after long ICU stays. This highly sensitive and specific prognostic test could prove useful in guiding clinical resource allocation.
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15
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Stukas S, Goshua G, Kinkade A, Grey R, Mah G, Biggs CM, Jamal S, Thiara S, Lau TT, Piszczek J, Partovi N, Sweet DD, Lee AY, Wellington CL, Sekhon MS, Chen LY. Reduced fixed dose tocilizumab 400 mg IV compared to weight-based dosing in critically ill patients with COVID-19: A before-after cohort study. The Lancet Regional Health - Americas 2022; 11:100228. [PMID: 35345649 PMCID: PMC8941850 DOI: 10.1016/j.lana.2022.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Interleukin-6 inhibitors reduce mortality in severe COVID-19. British Columbia began using tocilizumab 8 mg/kg (maximum 800 mg) in January 2021 in critically ill patients with COVID-19, but due to drug shortages, decreased dosing to 400 mg IV fixed dose in April 2021. The aims of this study were twofold: to compare physiological responses and clinical outcomes of these two strategies, and examine the cost-effectiveness of treating all patients with 400 mg versus half the patients with 8 mg/kg and the other half without tocilizumab. Methods This was a single-centre, before-after cohort study of critically ill COVID-19 patients treated with tocilizumab, and a control cohort treated with dexamethasone only. Physiological responses and clinical outcomes were compared between patients receiving both doses of tocilizumab and those receiving dexamethasone only. We built a decision tree model to examine cost-effectiveness. Findings 152 patients were included; 40 received tocilizumab 8 mg/kg, 59 received 400 mg and 53 received dexamethasone only. Median CRP fell from 103 mg/L to 5.2 mg/L, 96 mg/L to 6.8 mg/L and from 81.3 mg/L to 48 mg/L in the 8 mg/kg, 400 mg tocilizumab, and dexamethasone only groups, respectively. 28-day mortality was 5% (n=2) vs 8% (n=5) vs 13% (n=7), with no significant difference in all pair-wise comparison. At an assumed willingness-to-pay threshold of $50,000 Canadian per life-year, utilizing 400 mg for all patients rather than 8 mg/kg for half the patients is cost-effective in 51.6% of 10,000 Monte Carlo simulations. Interpretation Both doses of tocilizumab demonstrated comparable reduction of inflammation with similar 28-day mortality. Without consideration of equity, the net monetary benefits of providing 400 mg tocilizumab to all patients are comparable to 8 mg/kg to half the patients. In the context of ongoing drug shortages, fixed-dose 400 mg tocilizumab may be a practical, feasible and economical option. Funding This work was supported by a gift donation from Hsu & Taylor Family to the VGH Foundation, and the Yale Bernard G. Forget Scholarship.
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16
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Sekhon MS, Griesdale DE. Low field magnetic resonance imaging: A "beds-eye-d" view into hypoxic ischemic brain injury after cardiac arrest. Resuscitation 2022; 176:55-57. [PMID: 35605800 DOI: 10.1016/j.resuscitation.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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17
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Hoiland RL, Rikhraj KJK, Thiara S, Fordyce C, Kramer AH, Skrifvars MB, Wellington CL, Griesdale DE, Fergusson NA, Sekhon MS. Neurologic Prognostication After Cardiac Arrest Using Brain Biomarkers: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:390-398. [PMID: 35226054 PMCID: PMC8886448 DOI: 10.1001/jamaneurol.2021.5598] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Brain injury biomarkers released into circulation from the injured neurovascular unit are important prognostic tools in patients with cardiac arrest who develop hypoxic ischemic brain injury (HIBI) after return of spontaneous circulation (ROSC). OBJECTIVE To assess the neuroprognostic utility of bloodborne brain injury biomarkers in patients with cardiac arrest with HIBI. DATA SOURCES Studies in electronic databases from inception to September 15, 2021. These databases included MEDLINE, Embase, Evidence-Based Medicine Reviews, CINAHL, Cochrane Database of Systematic Reviews, and the World Health Organization Global Health Library. STUDY SELECTION Articles included in this systmatic review and meta-analysis were independently assessed by 2 reviewers. We included studies that investigated neuron-specific enolase, S100 calcium-binding protein β, glial fibrillary acidic protein, neurofilament light, tau, or ubiquitin carboxyl hydrolase L1 in patients with cardiac arrest aged 18 years and older for neurologic prognostication. We excluded studies that did not (1) dichotomize neurologic outcome as favorable vs unfavorable, (2) specify the timing of blood sampling or outcome determination, or (3) report diagnostic test accuracy or biomarker concentration. DATA EXTRACTION AND SYNTHESIS Data on the study design, inclusion and exclusion criteria, brain biomarkers levels, diagnostic test accuracy, and neurologic outcome were recorded. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. MAIN OUTCOMES AND MEASURES Summary receiver operating characteristic curve analysis was used to calculate the area under the curve, sensitivity, specificity, and optimal thresholds for each biomarker. Risk of bias and concerns of applicability were assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS We identified 2953 studies, of which 86 studies with 10 567 patients (7777 men [73.6] and 2790 women [26.4]; pooled mean [SD] age, 62.8 [10.2] years) were included. Biomarker analysis at 48 hours after ROSC demonstrated that neurofilament light had the highest predictive value for unfavorable neurologic outcome, with an area under the curve of 0.92 (95% CI, 0.84-0.97). Subgroup analyses of patients treated with targeted temperature management and those who specifically had an out-of-hospital cardiac arrest showed similar results (targeted temperature management, 0.92 [95% CI, 0.86-0.95] and out-of-hospital cardiac arrest, 0.93 [95% CI, 0.86-0.97]). CONCLUSIONS AND RELEVANCE Neurofilament light, which reflects white matter damage and axonal injury, yielded the highest accuracy in predicting neurologic outcome in patients with HIBI at 48 hours after ROSC. TRIAL REGISTRATION PROSPERO Identifier: CRD42020157366.
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Affiliation(s)
- Ryan L. Hoiland
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Kiran J. K. Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sharanjit Thiara
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andreas H. Kramer
- Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Markus B. Skrifvars
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Cheryl L. Wellington
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada,Department of Pathology and Laboratory Medicine, Faculty of Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald E. Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas A. Fergusson
- Faculty of Medicine, University of British Columbia, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mypinder S. Sekhon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada,Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Caldwell HG, Hoiland RL, Smith KJ, Brassard P, Bain AR, Tymko MM, Howe CA, Carr JM, Stacey BS, Bailey DM, Drapeau A, Sekhon MS, MacLeod DB, Ainslie PN. Trans-cerebral HCO 3- and PCO 2 exchange during acute respiratory acidosis and exercise-induced metabolic acidosis in humans. J Cereb Blood Flow Metab 2022; 42:559-571. [PMID: 34904461 PMCID: PMC8943603 DOI: 10.1177/0271678x211065924] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
This study investigated trans-cerebral internal jugular venous-arterial bicarbonate ([HCO3-]) and carbon dioxide tension (PCO2) exchange utilizing two separate interventions to induce acidosis: 1) acute respiratory acidosis via elevations in arterial PCO2 (PaCO2) (n = 39); and 2) metabolic acidosis via incremental cycling exercise to exhaustion (n = 24). During respiratory acidosis, arterial [HCO3-] increased by 0.15 ± 0.05 mmol ⋅ l-1 per mmHg elevation in PaCO2 across a wide physiological range (35 to 60 mmHg PaCO2; P < 0.001). The narrowing of the venous-arterial [HCO3-] and PCO2 differences with respiratory acidosis were both related to the hypercapnia-induced elevations in cerebral blood flow (CBF) (both P < 0.001; subset n = 27); thus, trans-cerebral [HCO3-] exchange (CBF × venous-arterial [HCO3-] difference) was reduced indicating a shift from net release toward net uptake of [HCO3-] (P = 0.004). Arterial [HCO3-] was reduced by -0.48 ± 0.15 mmol ⋅ l-1 per nmol ⋅ l-1 increase in arterial [H+] with exercise-induced acidosis (P < 0.001). There was no relationship between the venous-arterial [HCO3-] difference and arterial [H+] with exercise-induced acidosis or CBF; therefore, trans-cerebral [HCO3-] exchange was unaltered throughout exercise when indexed against arterial [H+] or pH (P = 0.933 and P = 0.896, respectively). These results indicate that increases and decreases in systemic [HCO3-] - during acute respiratory/exercise-induced metabolic acidosis, respectively - differentially affect cerebrovascular acid-base balance (via trans-cerebral [HCO3-] exchange).
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Affiliation(s)
- Hannah G Caldwell
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Kurt J Smith
- Department of Exercise Science, Physical and Health Education, Faculty of Education, University of Victoria, Victoria, British Columbia, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Anthony R Bain
- Faculty of Human Kinetics, Department of Kinesiology, University of Windsor, Windsor, ON, Canada
| | - Michael M Tymko
- Neurovascular Health Laboratory, Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, AB, Canada
| | - Connor A Howe
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Jay Mjr Carr
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Audrey Drapeau
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, 8167Vancouver General Hospital, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David B MacLeod
- Human Pharmacology and Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada
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19
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Leatherdale A, Stukas S, Lei V, West HE, Campbell CJ, Hoiland RL, Cooper J, Wellington CL, Sekhon MS, Pryzdial ELG, Conway EM. Persistently elevated complement alternative pathway biomarkers in COVID-19 correlate with hypoxemia and predict in-hospital mortality. Med Microbiol Immunol 2022; 211:37-48. [PMID: 35034207 PMCID: PMC8761108 DOI: 10.1007/s00430-021-00725-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/29/2021] [Indexed: 01/05/2023]
Abstract
Mechanisms underlying the SARS-CoV-2-triggered hyperacute thrombo-inflammatory response that causes multi-organ damage in coronavirus disease 2019 (COVID-19) are poorly understood. Several lines of evidence implicate overactivation of complement. To delineate the involvement of complement in COVID-19, we prospectively studied 25 ICU-hospitalized patients for up to 21 days. Complement biomarkers in patient sera and healthy controls were quantified by enzyme-linked immunosorbent assays. Correlations with respiratory function and mortality were analyzed. Activation of complement via the classical/lectin pathways was variably increased. Strikingly, all patients had increased activation of the alternative pathway (AP) with elevated levels of activation fragments, Ba and Bb. This was associated with a reduction of the AP negative regulator, factor (F) H. Correspondingly, terminal pathway biomarkers of complement activation, C5a and sC5b-9, were significantly elevated in all COVID-19 patient sera. C5a and AP constituents Ba and Bb, were significantly associated with hypoxemia. Ba and FD at the time of ICU admission were strong independent predictors of mortality in the following 30 days. Levels of all complement activation markers were sustained throughout the patients’ ICU stays, contrasting with the varying serum levels of IL-6, C-reactive protein, and ferritin. Severely ill COVID-19 patients have increased and persistent activation of complement, mediated strongly via the AP. Complement activation biomarkers may be valuable measures of severity of lung disease and the risk of mortality. Large-scale studies will reveal the relevance of these findings to thrombo-inflammation in acute and post-acute COVID-19.
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Affiliation(s)
- Alexander Leatherdale
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Victor Lei
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Henry E West
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Vancouver, BC, Canada
| | - Jennifer Cooper
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Edward L G Pryzdial
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Centre for Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Edward M Conway
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada.
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada.
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20
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Griesdale DEG, Sekhon MS. Correspondence to: Elevated jugular venous oxygen saturation after cardiac arrest. Resuscitation 2022; 170:367-368. [PMID: 35086670 DOI: 10.1016/j.resuscitation.2021.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Donald E G Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 899 West 12(th) Avenue, V5Z 1M9 Vancouver, British Columbia, Canada.
| | - Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, 899 West 12(th) Avenue, V5Z 1M9 Vancouver, British Columbia, Canada.
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21
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Hoiland RL, Caldwell HG, Carr JMJR, Howe CA, Stacey BS, Dawkins T, Wakeham DJ, Tremblay JC, Tymko MM, Patrician A, Smith KJ, Sekhon MS, MacLeod DB, Green DJ, Bailey DM, Ainslie PN. Nitric oxide contributes to cerebrovascular shear-mediated dilatation but not steady-state cerebrovascular reactivity to carbon dioxide. J Physiol 2021; 600:1385-1403. [PMID: 34904229 DOI: 10.1113/jp282427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/07/2021] [Indexed: 12/15/2022] Open
Abstract
Cerebrovascular CO2 reactivity (CVR) is often considered a bioassay of cerebrovascular endothelial function. We recently introduced a test of cerebral shear-mediated dilatation (cSMD) that may better reflect endothelial function. We aimed to determine the nitric oxide (NO)-dependency of CVR and cSMD. Eleven volunteers underwent a steady-state CVR test and transient CO2 test of cSMD during intravenous infusion of the NO synthase inhibitor NG -monomethyl-l-arginine (l-NMMA) or volume-matched saline (placebo; single-blinded and counter-balanced). We measured cerebral blood flow (CBF; duplex ultrasound), intra-arterial blood pressure and P aC O 2 . Paired arterial and jugular venous blood sampling allowed for the determination of trans-cerebral NO2 - exchange (ozone-based chemiluminescence). l-NMMA reduced arterial NO2 - by ∼25% versus saline (74.3 ± 39.9 vs. 98.1 ± 34.2 nM; P = 0.03). The steady-state CVR (20.1 ± 11.6 nM/min at baseline vs. 3.2 ± 16.7 nM/min at +9 mmHg P aC O 2 ; P = 0.017) and transient cSMD tests (3.4 ± 5.9 nM/min at baseline vs. -1.8 ± 8.2 nM/min at 120 s post-CO2 ; P = 0.044) shifted trans-cerebral NO2 - exchange towards a greater net release (a negative value indicates release). Although this trans-cerebral NO2 - release was abolished by l-NMMA, CVR did not differ between the saline and l-NMMA trials (57.2 ± 14.6 vs. 54.1 ± 12.1 ml/min/mmHg; P = 0.49), nor did l-NMMA impact peak internal carotid artery dilatation during the steady-state CVR test (6.2 ± 4.5 vs. 6.2 ± 5.0% dilatation; P = 0.960). However, l-NMMA reduced cSMD by ∼37% compared to saline (2.91 ± 1.38 vs. 4.65 ± 2.50%; P = 0.009). Our findings indicate that NO is not an obligatory regulator of steady-state CVR. Further, our novel transient CO2 test of cSMD is largely NO-dependent and provides an in vivo bioassay of NO-mediated cerebrovascular function in humans. KEY POINTS: Emerging evidence indicates that a transient CO2 stimulus elicits shear-mediated dilatation of the internal carotid artery, termed cerebral shear-mediated dilatation. Whether or not cerebrovascular reactivity to a steady-state CO2 stimulus is NO-dependent remains unclear in humans. During both a steady-state cerebrovascular reactivity test and a transient CO2 test of cerebral shear-mediated dilatation, trans-cerebral nitrite exchange shifted towards a net release indicating cerebrovascular NO production; this response was not evident following intravenous infusion of the non-selective NO synthase inhibitor NG -monomethyl-l-arginine. NO synthase blockade did not alter cerebrovascular reactivity in the steady-state CO2 test; however, cerebral shear-mediated dilatation following a transient CO2 stimulus was reduced by ∼37% following intravenous infusion of NG -monomethyl-l-arginine. NO is not obligatory for cerebrovascular reactivity to CO2 , but is a key contributor to cerebral shear-mediated dilatation.
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Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Hannah G Caldwell
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Jay M J R Carr
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Connor A Howe
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Tony Dawkins
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Denis J Wakeham
- Cardiff School of Sport and Health Sciences, Cardiff Metropolitan University, Cardiff, UK
| | - Joshua C Tremblay
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Michael M Tymko
- Neurovascular Health Laboratory, University of Alberta, Edmonton, Alberta, Canada
| | - Alexander Patrician
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Kurt J Smith
- Integrative Physiology Laboratory, Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA.,Cerebrovascular Health, Exercise, and Environmental Research Science (CHEERS) Laboratory, School of Exercise Science, Physical and Health Education, Faculty of Education, University of Victoria, Victoria, British Columbia, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - David B MacLeod
- Human Pharmacology and Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Daniel J Green
- School of Human Sciences (Exercise and Sport Sciences), University of Western Australia, Nedlands, Western Australia, Australia
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Philip N Ainslie
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
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22
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Sekhon MS, Hoiland RL, Griesdale DE. The importance of the oxygen cascade after cardiac arrest. Resuscitation 2021; 168:231-233. [PMID: 34592401 DOI: 10.1016/j.resuscitation.2021.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
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23
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Affiliation(s)
- Mypinder S Sekhon
- University of British Columbia, 8166, Vancouver, British Columbia, Canada;
| | - Sharanjit Thiara
- The University of British Columbia, 8166, Vancouver, British Columbia, Canada
| | - Hussein D Kanji
- The University of British Columbia, 8166, Vancouver, British Columbia, Canada
| | - Juan J Ronco
- Vancouver General Hospital Centennial Pavillion, 380154, Vancouver, British Columbia, Canada
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24
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Streijger F, Kim KT, So K, Manouchehri N, Shortt K, Okon EB, Morrison C, Fong A, Gupta R, Brown AA, Tigchelaar S, Sun J, Liu E, Keung M, Daly CD, Cripton PA, Sekhon MS, Griesdale DE, Kwon BK. Duraplasty in Traumatic Thoracic Spinal Cord Injury: Impact on Spinal Cord Hemodynamics, Tissue Metabolism, Histology, and Behavioral Recovery Using a Porcine Model. J Neurotrauma 2021; 38:2937-2955. [PMID: 34011164 DOI: 10.1089/neu.2021.0084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
After acute traumatic spinal cord injury (SCI), the spinal cord can swell to fill the subarachnoid space and become compressed by the surrounding dura. In a porcine model of SCI, we performed a duraplasty to expand the subarachnoid space around the injured spinal cord and evaluated how this influenced acute intraparenchymal hemodynamic and metabolic responses, in addition to histological and behavioral recovery. Female Yucatan pigs underwent a T10 SCI, with or without duraplasty. Using microsensors implanted into the spinal cord parenchyma, changes in blood flow (ΔSCBF), oxygenation (ΔPO2), and spinal cord pressure (ΔSCP) during and after SCI were monitored, alongside metabolic responses. Behavioral recovery was tested weekly using the Porcine Injury Behavior Scale (PTIBS). Thereafter, spinal cords were harvested for tissue sparing analyses. In both duraplasty and non-animals, the ΔSCP increased ∼5 mm Hg in the first 6 h post-injury. After this, the SCP appeared to be slightly reduced in the duraplasty animals, although the group differences were not statistically significant after controlling for injury severity in terms of impact force. During the first seven days post-SCI, the ΔSCBF or ΔPO2 values were not different between the duraplasty and control animals. Over 12 weeks, there was no improvement in hindlimb locomotion as assessed by PTIBS scores and no reduction in tissue damage at the injury site in the duraplasty animals. In our porcine model of SCI, duraplasty did not provide any clear evidence of long-term behavioral or tissue sparing benefit after SCI.
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Affiliation(s)
- Femke Streijger
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Kyoung-Tae Kim
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada.,Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea.,Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kitty So
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Neda Manouchehri
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Katelyn Shortt
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Elena B Okon
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Charlotte Morrison
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Allan Fong
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Rishab Gupta
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Aysha Allard Brown
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Seth Tigchelaar
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Jenny Sun
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Ella Liu
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Martin Keung
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Chris D Daly
- Vancouver Spine Surgery Institute, Department of Orthopaedics, and University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Peter A Cripton
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada.,School of Biomedical Engineering and Orthopedics, University of British Columbia (UBC), Vancouver, British Columbia, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine and Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries, University of British Columbia (UBC), Vancouver, British Columbia, Canada.,Vancouver Spine Surgery Institute, Department of Orthopaedics, and University of British Columbia (UBC), Vancouver, British Columbia, Canada
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25
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Hoiland RL, Griesdale DE, Sekhon MS. Invasive neuromonitoring post-cardiac arrest: Key considerations. Resuscitation 2021; 164:144-146. [PMID: 34000353 DOI: 10.1016/j.resuscitation.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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26
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Hoiland RL, Griesdale DE, Gooderham P, Sekhon MS. Intraparenchymal Neuromonitoring of Cerebral Fat Embolism Syndrome. Crit Care Explor 2021; 3:e0396. [PMID: 34079943 PMCID: PMC8162500 DOI: 10.1097/cce.0000000000000396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: We aimed to characterize the cerebrovascular physiology of cerebral fat embolism using invasive multimodal neuromonitoring. Data Sources: ICU, Vancouver General Hospital, Vancouver, BC, Canada. Study Selection: Case report. Data Extraction: Patient monitoring software (ICM+, Cambridge, United Kingdom), clinical records, and surgical records. Data Synthesis: None. Conclusions: Our integrated assessment of the cerebrovascular physiology of fat embolism syndrome provides a physiologic basis to investigate the importance of augmenting mean arterial pressure to optimize cerebral oxygen delivery for the mitigation of long-term neurologic ischemic sequelae of cerebral fat embolism.
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Affiliation(s)
- Ryan Leo Hoiland
- Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.,Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.,Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
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27
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Chen LYC, Biggs CM, Jamal S, Stukas S, Wellington CL, Sekhon MS. Soluble interleukin-6 receptor in the COVID-19 cytokine storm syndrome. Cell Rep Med 2021; 2:100269. [PMID: 33899032 PMCID: PMC8055165 DOI: 10.1016/j.xcrm.2021.100269] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Data suggest that interleukin (IL)-6 blockade could reduce mortality in severe COVID-19, yet IL-6 is only modestly elevated in most patients. Chen et al. describe the role of soluble interleukin-6 receptor (sIL-6R) in IL-6 trans-signaling and how understanding the IL-6:sIL-6R axis might help define and treat COVID-19 cytokine storm syndrome.
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Affiliation(s)
- Luke Y C Chen
- Division of Hematology, University of British Columbia, Vancouver, BC V5Z1M9, Canada.,Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC V6T1Z3, Canada
| | - Catherine M Biggs
- Division of Allergy and Immunology, University of British Columbia, Vancouver, BC V5Z1M9, Canada
| | - Shahin Jamal
- Division of Rheumatology, University of British Columbia, Vancouver, BC V5Z1M9, Canada
| | - Sophie Stukas
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC V5Z1M9, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC V6T1Z3, Canada
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC V5Z1M9, Canada.,Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC V6T1Z3, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC V5Z1M9, Canada
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Shepley BR, Ainslie PN, Hoiland RL, Donnelly J, Sekhon MS, Zetterberg H, Blennow K, Bain AR. Negligible influence of moderate to severe hyperthermia on blood-brain barrier permeability and neuronal parenchymal integrity in healthy men. J Appl Physiol (1985) 2021; 130:792-800. [PMID: 33444119 DOI: 10.1152/japplphysiol.00645.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
With growing use for hyperthermia as a cardiovascular therapeutic, there is surprisingly little information regarding the acute effects it may have on the integrity of the neurovascular unit (NVU). Indeed, relying on animal data would suggest hyperthermia comparable to levels attained in thermal therapy will disrupt the blood-brain barrier (BBB) and damage the cerebral parenchymal cells. We sought to address the hypothesis that controlled passive hyperthermia is not sufficient to damage the NVU in healthy humans. Young men (n = 11) underwent acute passive heating until +2°C or absolute esophageal temperature of 39.5°C. The presence of BBB opening was determined by trans-cerebral exchange kinetics (radial-arterial and jugular venous cannulation) of S100B. Neuronal parenchymal damage was determined by the trans-cerebral exchange of tau protein, neuron-specific enolase (NSE), and neurofilament-light protein (NF-L). Cerebral blood flow to calculate exchange kinetics was measured by duplex ultrasound of the right internal carotid and left vertebral artery. Passive heating was performed via a warm-water perfused suit. In hyperthermia, there was no increase in the cerebral exchange of S100B (P = 0.327), tau protein (P = 0.626), NF-L (P = 0.447), or NSE (P = 0.908) suggesting the +2°C core temperature is not sufficient to acutely stress the NVU in healthy men. However, there was a significant condition effect (P = 0.028) of NSE, corresponding to a significant increase in arterial (P = 0.023) but not venous (P = 0.173) concentrations in hyperthermia, potentially indicating extra-cerebral release of NSE. Collectively, results from the present study support the notion that in young men there is little concern for NVU damage with acute hyperthermia of +2 °C.NEW & NOTEWORTHY The acute effects of passive whole-body hyperthermia on the integrity of the neurovascular unit (NVU) in humans have remained unclear. We demonstrate that passive heating for ∼1 h until an increase of +2°C esophageal temperature in healthy men does not increase the cerebral release of neuronal parenchymal stress biomarkers, suggesting the NVU integrity is maintained. This preliminary study indicates passive heating is safe for the brain, at least in young healthy men.
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Affiliation(s)
- Brooke R Shepley
- University of Windsor, Faculty of Human Kinetics, Department of Kinesiology, Windsor, ON, Canada
| | - Philip N Ainslie
- University of British Columbia, Kelowna, Centre for Heart Lung and Vascular Health, Vancouver, BC, Canada
| | - Ryan L Hoiland
- University of British Columbia, Kelowna, Centre for Heart Lung and Vascular Health, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology, and Therapeutics, Vancouver General Hospital, Vancouver, BC, Canada
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Mypinder S Sekhon
- University of British Columbia, Kelowna, Centre for Heart Lung and Vascular Health, Vancouver, BC, Canada.,Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Anthony R Bain
- University of Windsor, Faculty of Human Kinetics, Department of Kinesiology, Windsor, ON, Canada
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Mitra AR, Fergusson NA, Lloyd-Smith E, Wormsbecker A, Foster D, Karpov A, Crowe S, Haljan G, Chittock DR, Kanji HD, Sekhon MS, Griesdale DEG. Caractéristiques de départ et issues chez des patients atteints de COVID-19 hospitalisés dans des unités de soins intensifs à Vancouver (Canada) : série de cas. CMAJ 2020; 192:E1550-E1558. [PMID: 33229353 DOI: 10.1503/cmaj.200794-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Anish R Mitra
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Nicholas A Fergusson
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Elisa Lloyd-Smith
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Andrew Wormsbecker
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Denise Foster
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Andrei Karpov
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Sarah Crowe
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Greg Haljan
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Dean R Chittock
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Hussein D Kanji
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Mypinder S Sekhon
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B
| | - Donald E G Griesdale
- Division de médecine de soins intensifs, Département de médecine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), Université de la Colombie-Britannique, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Mitra, Haljan), Hôpital Surrey Memorial, Surrey, C.-B.; programme de doctorat en médecine (Fergusson), Université de la Colombie-Britannique; Qualité et sécurité des patients (Fergusson, Lloyd-Smith), régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.; Division de médecine de soins intensifs, Département de médecine (Wormsbecker), Hôpital Royal Columbian, New Westminster, C.-B.; Division de médecine de soins intensifs, Département des infirmières praticiennes (Crowe), Hôpital Surrey Memorial, Surrey, C.-B.; Programme de soins intensifs (Chittock, Kanji, Sekhon, Griesdale), Hôpital général de Vancouver; Départements d'anesthésiologie, de pharmacologie et de thérapeutique (Griesdale), Université de la Colombie-Britannique; Centre d'épidémiologie et d'évaluation clinique (Griesdale), Institut de recherche de la régie régionale de la santé Vancouver Coastal, Vancouver, C.-B.
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Cooper J, Stukas SK, Hoiland R, Thiara S, Foster D, Mitra A, Panenka WJ, Sekhon MS, Wellington CL. Quantification of neurological blood‐based biomarkers in critically ill patients with COVID‐19. Alzheimers Dement 2020. [PMCID: PMC7883192 DOI: 10.1002/alz.047682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Ryan Hoiland
- University of British Columbia Vancouver BC Canada
| | - Sonny Thiara
- University of British Columbia Vancouver BC Canada
| | | | - Anish Mitra
- University of British Columbia Vancouver BC Canada
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Hoiland RL, Fergusson NA, Mitra AR, Griesdale DEG, Devine DV, Stukas S, Cooper J, Thiara S, Foster D, Chen LYC, Lee AYY, Conway EM, Wellington CL, Sekhon MS. The association of ABO blood group with indices of disease severity and multiorgan dysfunction in COVID-19. Blood Adv 2020; 4:4981-4989. [PMID: 33057633 PMCID: PMC7594392 DOI: 10.1182/bloodadvances.2020002623] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023] Open
Abstract
Studies on severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) suggest a protective effect of anti-A antibodies against viral cell entry that may hold relevance for SARS-CoV-2 infection. Therefore, we aimed to determine whether ABO blood groups are associated with different severities of COVID-19. We conducted a multicenter retrospective analysis and nested prospective observational substudy of critically ill patients with COVID-19. We collected data pertaining to age, sex, comorbidities, dates of symptom onset, hospital admission, intensive care unit (ICU) admission, mechanical ventilation, continuous renal replacement therapy (CRRT), standard laboratory parameters, and serum inflammatory cytokines. National (N = 398 671; P = .38) and provincial (n = 62 246; P = .60) ABO blood group distributions did not differ from our cohort (n = 95). A higher proportion of COVID-19 patients with blood group A or AB required mechanical ventilation (P = .02) and CRRT (P = .004) and had a longer ICU stay (P = .03) compared with patients with blood group O or B. Blood group A or AB also had an increased probability of requiring mechanical ventilation and CRRT after adjusting for age, sex, and presence of ≥1 comorbidity. Inflammatory cytokines did not differ between patients with blood group A or AB (n = 11) vs O or B (n = 14; P > .10 for all cytokines). Collectively, our data indicate that critically ill COVID-19 patients with blood group A or AB are at increased risk for requiring mechanical ventilation, CRRT, and prolonged ICU admission compared with patients with blood group O or B. Further work is needed to understand the underlying mechanisms.
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Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia-Okanagan, Kelowna, BC, Canada
| | - Nicholas A Fergusson
- MD Undergraduate Program, University of British Columbia, Vancouver, BC, Canada
- Medicine, Quality, and Safety, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Medicine, Quality, and Safety, Vancouver Coastal Health, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Dana V Devine
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Canadian Blood Services, Ottawa, ON, Canada; and
- Centre for Blood Research, Life Sciences Institute
| | - Sophie Stukas
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Cooper
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Edward M Conway
- Centre for Blood Research, Life Sciences Institute
- Division of Hematology, Department of Medicine
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health
- School of Biomedical Engineering, and
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Chen LYC, Hoiland RL, Stukas S, Wellington CL, Sekhon MS. Confronting the controversy: interleukin-6 and the COVID-19 cytokine storm syndrome. Eur Respir J 2020; 56:2003006. [PMID: 32883678 PMCID: PMC7474149 DOI: 10.1183/13993003.03006-2020] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022]
Abstract
The concept of coronavirus disease 2019 (COVID-19)-related cytokine storm syndrome (COVID-CSS) emerged early in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic to explain why some patients exposed to this virus become critically ill with acute respiratory distress syndrome, multi-organ failure, and death. A seminal study from Wuhan, China reported higher serum concentrations of inflammatory cytokines in patients requiring critical care compared to those with milder disease, and the authors postulated that “cytokine storm was associated with disease severity” [1]. Hypercytokinaemic immune dysregulation in COVID-19 is known as cytokine storm syndrome. Interleukin-6 levels ≥80 pg·mL−1 predict an increased risk of respiratory failure and death, and immunomodulatory therapy is an area of urgent investigation. https://bit.ly/3jq3uJ4
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Affiliation(s)
- Luke Y C Chen
- Division of Hematology, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
| | - Ryan L Hoiland
- Dept of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Dept of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sophie Stukas
- Dept of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl L Wellington
- Dept of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Dept of Medicine, University of British Columbia, Vancouver, BC, Canada
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Fergusson NA, Ahkioon S, Ayas N, Dhingra VK, Chittock DR, Sekhon MS, Mitra AR, Griesdale DEG. Association between intensive care unit occupancy at discharge, afterhours discharges, and clinical outcomes: a historical cohort study. Can J Anaesth 2020; 67:1359-1370. [PMID: 32720255 DOI: 10.1007/s12630-020-01762-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 01/08/2023] Open
Abstract
PURPOSE There is a paucity of evidence evaluating whether intensive care unit (ICU) discharge occupancy is associated with clinical outcomes. It is unknown whether increased discharge occupancy leads to greater afterhours discharges and downstream consequences. We explore the association between ICU discharge occupancy and afterhours discharges, 72-hr readmission, and 30-day mortality. METHODS This single-centre, historical cohort study included all patients discharged from the Vancouver General Hospital ICU between 5 April 2010 and 13 September 2017. Data were obtained from the British Columbia Critical Care Database. Occupancy was defined as the number of ICU bed hours utilized divided by the available bed hours for that day. Any discharge between 22:00 and 6:59 was considered afterhours. Logistic regression models adjusting for important covariates were constructed. RESULTS We included 8,862 ICU discharges representing 7,288 individual patients. There were 1,180 (13.3%) afterhours discharges, 408 (4.6%) 72-hr readmissions, and 574 (6.5%) 30-day post-discharge deaths. Greater discharge occupancy was associated with afterhours discharges (per 10% increase: adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 1.03 to 1.20; P = 0.005). Discharge occupancy was not associated with 72-hr readmission (per 10% increase: aOR, 0.97; 95% CI, 0.87 to 1.09; P = 0.62) or 30-day mortality (per 10% increase: aOR, 1.05; 95% CI, 0.95 to 1.16; P = 0.32). Afterhours discharge was not associated with 72-hr readmission (aOR, 1.15; 95% CI, 0.86 to 1.54; P = 0.34) or 30-day mortality (aOR, 1.05; 95% CI, 0.82 to 1.36; P = 0.69). CONCLUSIONS Greater ICU discharge occupancy was associated with a significant increase in afterhours discharges. Nevertheless, neither discharge occupancy nor afterhours discharge were associated with 72-hr readmission or 30-day mortality.
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Affiliation(s)
| | | | - Najib Ayas
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Vinay K Dhingra
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Dean R Chittock
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
- Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
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Hoiland RL, Caldwell HG, Howe CA, Nowak-Flück D, Stacey BS, Bailey DM, Paton JFR, Green DJ, Sekhon MS, Macleod DB, Ainslie PN. Nitric oxide is fundamental to neurovascular coupling in humans. J Physiol 2020; 598:4927-4939. [PMID: 32785972 DOI: 10.1113/jp280162] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 08/06/2020] [Indexed: 12/27/2022] Open
Abstract
KEY POINTS Preclinical models have demonstrated that nitric oxide is a key component of neurovascular coupling; this has yet to be translated to humans. We conducted two separate protocols utilizing intravenous infusion of a nitric oxide synthase inhibitor and isovolumic haemodilution to assess the influence of nitric oxide on neurovascular coupling in humans. Isovolumic haemodilution did not alter neurovascular coupling. Intravenous infusion of a nitric oxide synthase inhibitor reduced the neurovascular coupling response by ∼30%, indicating that nitric oxide is integral to neurovascular coupling in humans. ABSTRACT Nitric oxide is a vital neurovascular signalling molecule in preclinical models, yet the mechanisms underlying neurovascular coupling (NVC) in humans have yet to be elucidated. To investigate the contribution of nitric oxide to NVC in humans, we utilized a visual stimulus paradigm to elicit an NVC response in the posterior cerebral circulation. Two distinct mechanistic interventions were conducted on young healthy males: (1) NVC was assessed during intravenous infusion of saline (placebo) and the non-selective competitive nitric oxide synthase inhibitor NG -monomethyl-l-arginine (l-NMMA, 5 mg kg-1 bolus & subsequent 50 μg kg-1 min-1 maintenance dose; n = 10). The order of infusion was randomized, counterbalanced and single blinded. A subset of participants in this study (n = 4) underwent a separate intervention with phenylephrine infusion to independently consider the influence of blood pressure changes on NVC (0.1-0.6 μg kg-1 min-1 constant infusion). (2) NVC was assessed prior to and following isovolumic haemodilution, whereby 20% of whole blood was removed and replaced with 5% human serum albumin to reduce haemoglobin concentration (n = 8). For both protocols, arterial and internal jugular venous blood samples were collected at rest and coupled with volumetric measures of cerebral blood flow (duplex ultrasound) to quantify resting cerebral metabolic parameters. l-NMMA elicited a 30% reduction in the peak (P = 0.01), but not average (P = 0.11), NVC response. Neither phenylephrine nor haemodilution influenced NVC. Nitric oxide signalling is integral to NVC in humans, providing a new direction for research into pharmacological treatment of humans with dementia.
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Affiliation(s)
- Ryan L Hoiland
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, V1V 1V7, Canada.,Department of Anesthesiology, Pharmacology, and Therapeutics, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Hannah G Caldwell
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, V1V 1V7, Canada
| | - Connor A Howe
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, V1V 1V7, Canada
| | - Daniela Nowak-Flück
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, V1V 1V7, Canada
| | - Benjamin S Stacey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, CF37 4BB, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, CF37 4BB, UK
| | - Julian F R Paton
- Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland, Park Road, Grafton, Auckland, 1142, New Zealand
| | - Daniel J Green
- School of Human Sciences (Exercise and Sport Sciences), The University of Western Australia, Nedlands, Western Australia, 6009, Australia
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - David B Macleod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27708, USA
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, V1V 1V7, Canada
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Hoiland RL, Griesdale DE, Sekhon MS. Assessing autoregulation using near infrared spectroscopy: more questions than answers. Resuscitation 2020; 156:280-281. [PMID: 32858154 DOI: 10.1016/j.resuscitation.2020.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Hoiland RL, Stukas S, Cooper J, Thiara S, Chen LYC, Biggs CM, Hay K, Lee AYY, Shojania K, Abdulla A, Wellington CL, Sekhon MS. Amelioration of COVID-19-related cytokine storm syndrome: parallels to chimeric antigen receptor-T cell cytokine release syndrome. Br J Haematol 2020; 190:e150-e154. [PMID: 32584416 PMCID: PMC7361645 DOI: 10.1111/bjh.16961] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Sophie Stukas
- Department of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Cooper
- Department of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sonny Thiara
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Luke Y C Chen
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Catherine M Biggs
- Division of Allergy and Immunology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kevin Hay
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kamran Shojania
- Division of Rheumatology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alym Abdulla
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl L Wellington
- Department of Pathology and Laboratory Medicine, International Collaboration on Repair Discoveries, School of Biomedical Engineering, Djavad Mowafaghian Centre for Brain Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Rikhraj KJK, Wood MD, Hoiland RL, Thiara S, Griesdale DEG, Sekhon MS. Determining Optimal Mean Arterial Pressure After Cardiac Arrest: A Systematic Review. Neurocrit Care 2020; 34:621-634. [PMID: 32572823 DOI: 10.1007/s12028-020-01027-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of cerebral autoregulation monitoring to identify patient-specific optimal mean arterial pressure (MAPOPT) has emerged as a technique to augment cerebral oxygen delivery in post-cardiac arrest patients. Our systematic review aims to determine (a) the average MAPOPT in these patients, (b) the feasibility of identifying MAPOPT, (c) the brain tissue oxygenation levels when MAP is within proximity to the MAPOPT and (d) the relationship between neurological outcome and MAPOPT-targeted resuscitation strategies. We carried out this review in accordance with the PRISMA guidelines. We included all studies that used cerebral autoregulation to determine MAPOPT in adult patients (> 16 years old) who achieved return of spontaneous circulation (ROSC) following cardiac arrest. All studies had to include our primary outcome of MAPOPT. We excluded studies where the patients had any history of traumatic brain injury, ischemic stroke or intracranial hemorrhage. We identified six studies with 181 patients. There was wide variability in cerebral autoregulation monitoring methods, length of monitoring, calculation and reporting of MAPOPT. Amongst all studies, the median or mean MAPOPT was consistently above 65 mmHg (range 70-114 mmHg). Definitions of feasibility varied among studies and were difficult to summarize. Only one study noted that brain tissue oxygenation increased as patients' MAP approached MAPOPT. There was no consistent association between targeting MAPOPT and improved neurological outcome. There is considerable heterogeneity in MAPOPT due to differences in monitoring methods of autoregulation. Further research is needed to assess the clinical utility of MAPOPT-guided strategies on decreasing secondary injury and improving neurological outcomes after ROSC.
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Affiliation(s)
- Kiran J K Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Michael D Wood
- Department of Anaesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Ryan L Hoiland
- Department of Anaesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, 3333 University Way, Kelowna, BC, V1V1V7, Canada
| | - Sharanjit Thiara
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Donald E G Griesdale
- Department of Anaesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
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38
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Mitra AR, Fergusson NA, Lloyd-Smith E, Wormsbecker A, Foster D, Karpov A, Crowe S, Haljan G, Chittock DR, Kanji HD, Sekhon MS, Griesdale DEG. Baseline characteristics and outcomes of patients with COVID-19 admitted to intensive care units in Vancouver, Canada: a case series. CMAJ 2020; 192:E694-E701. [PMID: 32461326 DOI: 10.1503/cmaj.200794] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Pandemic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with high intensive care unit (ICU) mortality. We aimed to describe the clinical characteristics and outcomes of critically ill patients with coronavirus disease 2019 (COVID-19) in a Canadian setting. METHODS We conducted a retrospective case series of critically ill patients with laboratory-confirmed SARS-CoV-2 infection consecutively admitted to 1 of 6 ICUs in Metro Vancouver, British Columbia, Canada, between Feb. 21 and Apr. 14, 2020. Demographic, management and outcome data were collected by review of patient charts and electronic medical records. RESULTS Between Feb. 21 and Apr. 14, 2020, 117 patients were admitted to the ICU with a confirmed diagnosis of COVID-19. The median age was 69 (interquartile range [IQR] 60-75) years, and 38 (32.5%) were female. At least 1 comorbidity was present in 86 (73.5%) patients. Invasive mechanical ventilation was required in 74 (63.2%) patients. The duration of mechanical ventilation was 13.5 (IQR 8-22) days overall and 11 (IQR 6-16) days for patients successfully discharged from the ICU. Tocilizumab was administered to 4 patients and hydroxychloroquine to 1 patient. As of May 5, 2020, a total of 18 (15.4%) patients had died, 12 (10.3%) remained in the ICU, 16 (13.7%) were discharged from the ICU but remained in hospital, and 71 (60.7%) were discharged home. INTERPRETATION In our setting, mortality in critically ill patients with COVID-19 admitted to the ICU was lower than in previously published studies. These data suggest that the prognosis associated with critical illness due to COVID-19 may not be as poor as previously reported.
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Affiliation(s)
- Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Nicholas A Fergusson
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Elisa Lloyd-Smith
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Andrew Wormsbecker
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Andrei Karpov
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Sarah Crowe
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Greg Haljan
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Dean R Chittock
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Hussein D Kanji
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
| | - Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine (Mitra, Wormsbecker, Foster, Karpov, Haljan, Chittock, Kanji, Sekhon, Griesdale), University of British Columbia, Vancouver, BC; Division of Critical Care Medicine, Department of Medicine (Mitra, Haljan), Surrey Memorial Hospital, Surrey, BC; MD Undergraduate Program (Fergusson), University of British Columbia; Quality & Patient Safety (Fergusson, Lloyd-Smith), Vancouver Coastal Health, Vancouver BC; Division of Critical Care Medicine, Department of Medicine (Wormsbecker), Royal Columbian Hospital, New Westminster, BC; Division of Critical Care Medicine, Department of Nurse Practitioners (Crowe), Surrey Memorial Hospital, Surrey, BC; Program of Critical Care (Chittock, Kanji, Sekhon, Griesdale), Vancouver General Hospital; Department of Anesthesiology, Pharmacology & Therapeutics (Griesdale), University of British Columbia; Centre for Clinical Epidemiology and Evaluation (Griesdale), Vancouver Coastal Health Research Institute, Vancouver, BC
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Lyden P, Kapinos G, Sekhon MS, Levi AD. Temperature Management in Neurological and Neurosurgical Intensive Care Unit. Ther Hypothermia Temp Manag 2020; 10:86-90. [PMID: 32326850 DOI: 10.1089/ther.2020.29072.pjl] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Gregory Kapinos
- Department of Neurology, SUNY Downstate College of Medicine, New York, New York, USA
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Vancouver General Hospital of British Columbia, Vancouver, Canada
| | - Allan D Levi
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Hoiland RL, Sekhon MS, Cardim D, Wood MD, Gooderham P, Foster D, Griesdale DE. Lack of agreement between optimal mean arterial pressure determination using pressure reactivity index versus cerebral oximetry index in hypoxic ischemic brain injury after cardiac arrest. Resuscitation 2020; 152:184-191. [PMID: 32229218 DOI: 10.1016/j.resuscitation.2020.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/13/2020] [Accepted: 03/21/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Invasive monitoring of cerebral autoregulation using the pressure reactivity index (PRx) allows for the determination of optimal mean arterial pressure (MAPOPT) in hypoxic ischemic brain injury (HIBI) patients following cardiac arrest. However, the utility of non-invasive surrogates to determine MAPOPT has not been addressed. We aimed to determine the agreement between PRx-derived MAPOPT versus MAPOPT determined by the near-infrared spectroscopy (NIRS) based cerebral oximetry index (COx). METHODS Ten HIBI patients were enrolled. PRx-derived MAPOPT, lower (LLA) and upper limits of autoregulation (ULA) were compared against COx-derived MAPOPT, LLA and ULA. Multimodal neuromonitoring included mean arterial pressure, intracranial pressure, brain tissue oxygenation, jugular venous oxygen saturation, and NIRS-derived regional cerebral oxygen saturation. RESULTS Repeated measures Bland-Altman plots demonstrated limited agreement between MAPOPT derived from COx and PRx (mean bias: 1.4 mmHg; upper limit of agreement: 25.9 mmHg; lower limit of agreement: -23.0 mmHg). Similarly, there was limited agreement between the absolute values of PRx and COx. Mean bias was 0.26 and the upper and lower limits of agreement were 1.05 and -0.53, respectively. Systematic bias was apparent, whereby at low PRx values COx overestimated PRx and at high PRx values, COx underestimated PRx. COx was limited in its ability to determine impaired autoregulation defined by PRx (receiver operator characteristic area under the curve was 0.488). CONCLUSION Collectively, we demonstrate that COx-based determination of MAPOPT lacks agreement with MAPOPT derived from PRx. Further research must be done to evaluate the physiologic and clinical efficacy of PRx derived MAPOPT in HIBI.
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Affiliation(s)
- Ryan L Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Centre for Heart, Lung, & Vascular Health, School of Health and Exercise Sciences, University of British Columbia-Okanagan, Kelowna, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Michael D Wood
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.
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Stubbs JL, Green KE, Silverberg ND, Howard A, Dhariwal AK, Brubacher JR, Garraway N, Heran MKS, Sekhon MS, Aquino A, Purcell V, Hutchison JS, Torres IJ, Panenka WJ. Atypical Somatic Symptoms in Adults With Prolonged Recovery From Mild Traumatic Brain Injury. Front Neurol 2020; 11:43. [PMID: 32117012 PMCID: PMC7010927 DOI: 10.3389/fneur.2020.00043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
Somatization may contribute to persistent symptoms after mild traumatic brain injury (mTBI). In two independently-recruited study samples, we characterized the extent to which symptoms atypical of mTBI but typical for patients suffering from somatization (e.g., gastrointestinal upset, musculoskeletal, and cardiorespiratory complaints) were present in adult patients with prolonged recovery following mTBI. The first sample was cross-sectional and consisted of mTBI patients recruited from the community who reported ongoing symptoms attributable to a previous mTBI (n = 16) along with a healthy control group (n = 15). The second sample consisted of patients with mTBI prospectively recruited from a Level 1 trauma center who had either good recovery (GOSE = 8; n = 32) or poor recovery (GOSE < 8; n = 29). In all participants, we evaluated atypical somatic symptoms using the Patient Health Questionnaire-15 and typical post-concussion symptoms with the Rivermead Post-Concussion Symptom Questionnaire. Participants with poor recovery from mTBI had significantly higher "atypical" somatic symptoms as compared to the healthy control group in Sample 1 (b = 4.308, p < 0.001) and to mTBI patients with good recovery in Sample 2 (b = 3.169, p < 0.001). As would be expected, participants with poor outcome in Sample 2 had a higher burden of typical rather than atypical symptoms [t (28) = 4.750, p < 0.001, d = 0.88]. However, participants with poor recovery still reported atypical somatic symptoms that were significantly higher (1.4 standard deviations, on average) than those with good recovery. Our results suggest that although "typical" post-concussion symptoms predominate after mTBI, a broad range of somatic symptoms also frequently accompanies mTBI, and that somatization may represent an important, modifiable factor in mTBI recovery.
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Affiliation(s)
- Jacob L Stubbs
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,British Columbia Neuropsychiatry Program, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Katherine E Green
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Noah D Silverberg
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada.,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Andrew Howard
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,British Columbia Neuropsychiatry Program, University of British Columbia, Vancouver, BC, Canada
| | - Amrit K Dhariwal
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Naisan Garraway
- Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Manraj K S Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Angela Aquino
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Victoria Purcell
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - James S Hutchison
- Department of Critical Care, The Hospital for Sick Children, Toronto, ON, Canada.,Neuroscience and Mental Health Research Program, Hospital for Sick Children Research Institute, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ivan J Torres
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William J Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.,British Columbia Neuropsychiatry Program, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
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42
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Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Kyeremanteng K, English SW, Sekhon MS, Griesdale DEG, Dowlatshahi D, McCredie VA, Wijdicks EFM, Almenawer SA, Inaba K, Rajajee V, Perry JJ. Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis. BMJ 2019; 366:l4225. [PMID: 31340932 PMCID: PMC6651068 DOI: 10.1136/bmj.l4225] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To summarise and compare the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial Doppler pulsatility index (TCD-PI) for the diagnosis of elevated intracranial pressure (ICP) in critically ill patients. DESIGN Systematic review and meta-analysis. DATA SOURCES Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018. STUDY SELECTION CRITERIA English language studies investigating accuracy of physical examination, imaging, or non-invasive tests among critically ill patients. The reference standard was ICP of 20 mm Hg or more using invasive ICP monitoring, or intraoperative diagnosis of raised ICP. DATA EXTRACTION Two reviewers independently extracted data and assessed study quality using the quality assessment of diagnostic accuracy studies tool. Summary estimates were generated using a hierarchical summary receiver operating characteristic (ROC) model. RESULTS 40 studies (n=5123) were included. Of physical examination signs, pooled sensitivity and specificity for increased ICP were 28.2% (95% confidence interval 16.0% to 44.8%) and 85.9% (74.9% to 92.5%) for pupillary dilation, respectively; 54.3% (36.6% to 71.0%) and 63.6% (46.5% to 77.8%) for posturing; and 75.8% (62.4% to 85.5%) and 39.9% (26.9% to 54.5%) for Glasgow coma scale of 8 or less. Among CT findings, sensitivity and specificity were 85.9% (58.0% to 96.4%) and 61.0% (29.1% to 85.6%) for compression of basal cisterns, respectively; 80.9% (64.3% to 90.9%) and 42.7% (24.0% to 63.7%) for any midline shift; and 20.7% (13.0% to 31.3%) and 89.2% (77.5% to 95.2%) for midline shift of at least 10 mm. The pooled area under the ROC (AUROC) curve for ONSD sonography was 0.94 (0.91 to 0.96). Patient level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55 to 0.72). CONCLUSIONS Absence of any one physical examination feature is not sufficient to rule out elevated ICP. Substantial midline shift could suggest elevated ICP, but the absence of shift cannot rule it out. ONSD sonography might have use, but further studies are needed. Suspicion of elevated ICP could necessitate treatment and transfer, regardless of individual non-invasive tests. REGISTRATION PROSPERO CRD42018105642.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Divison of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Saleh A Almenawer
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Venkatakrishna Rajajee
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Sekhon MS, Griesdale DE, Ainslie PN, Gooderham P, Foster D, Czosnyka M, Robba C, Cardim D. Intracranial pressure and compliance in hypoxic ischemic brain injury patients after cardiac arrest. Resuscitation 2019; 141:96-103. [PMID: 31185256 DOI: 10.1016/j.resuscitation.2019.05.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/17/2019] [Accepted: 05/29/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In hypoxic ischemic brain injury (HIBI), increased intracranial pressure (ICP) can ensue from cerebral edema stemming from cytotoxic and vasogenic mechanisms. Downstream sequelae of restricted cerebral blood flow lead to neurologic braindeath. There is limited data characterizing the temporal trends and patterns of ICP and compliance in human HIBI patients. METHODS Patients underwent invasive ICP monitoring with a parenchymal probe (Camino) and were managed with a tier-based management algorithm for elevated ICP. Data pertaining to mean arterial pressure (MAP), ICP, brain tissue oxygenation (PbtO2), end tidal carbon dioxide (ETCO2), core body temperature and RAP (moving correlation coefficient between mean ICP and its mean pulse amplitude) as a measure of intracranial compliance were recorded in the ICM + software. Data pertaining to ICP lowering interventions was also collected. RESULTS Ten patients were included with a median age of 47 (range 20-71) and seven were male (7/10). The mean ICP was 14 mmHg (SD 11) and time of ICP> 20 mmHg was 22% (range 0-100). The mean MAP, ETCO2 and temperature were 89 mmHg (SD 13), 31 mmHg (SD 7), 35.7 °C (SD 0.9), respectively. The mean RAP was 0.58 (SD 0.34) and time of RAP > 0.4 was 78% (range 57-97). There were no significant relationships between ETCO2 and temperature with ICP. CONCLUSIONS In our cohort, HIBI was characterized by normal ICP but with limited intracranial compliance. However, significant in between patient heterogeneity exists with respect to temporal patterns of intracranial pressure - volume relationships in HIBI. TRIAL REGISTRATION clinicaltrials.gov (NCT03609333).
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada.
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada; Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 899 West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Philip N Ainslie
- Department of Health and Exercise Sciences, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M96, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrookes Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Chiara Robba
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrookes Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Danilo Cardim
- Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
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Cardim D, Griesdale DE, Ainslie PN, Robba C, Calviello L, Czosnyka M, Smielewski P, Sekhon MS. A comparison of non-invasive versus invasive measures of intracranial pressure in hypoxic ischaemic brain injury after cardiac arrest. Resuscitation 2019; 137:221-228. [PMID: 30629992 DOI: 10.1016/j.resuscitation.2019.01.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/23/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
AIM Increased intracranial pressure (ICP) in hypoxic ischaemic brain injury (HIBI) can cause secondary ischaemic brain injury and culminate in brain death. Invasive ICP monitoring is limited by associated risks in HIBI patients. We sought to evaluate the agreement between invasive ICP measurements and non-invasive estimators of ICP (nICP) in HIBI patients. METHODS Eligible consecutive adult (age>18) cardiac arrest patients with HIBI were included as part of a single centre prospective interventional study. Invasive ICP monitoring and nICP measurements were undertaken using: a) transcranial Doppler ultrasonography (TCD), b) optic nerve sheet diameter ultrasound (ONSD) and c) jugular venous bulb pressure (JVP). Multiple measurements applied in linear mixed-effects models were considered to obtain the correlation coefficient between ICP and nICP as well as their predictive abilities to detect intracranial hypertension (ICP≥20mm Hg). RESULTS Eleven patients were included (median age of 47 [range 20-71], 8 males and 3 females). There was a linear relationship between ICP and nICP with ONSD (R=0.53 [p<0.0001]), JVP (R=0.38 [p<0.001]) and TCD (R=0.30 [p<0.01]). The ability to predict intracranial hypertension was highest for ONSD and TCD (area under the receiver operating curve (AUC)=0.96 [95% CI: 0.90-1.00] and AUC=0.91 [95% CI: 0.83-1.00], respectively). JVP presented the weakest prediction ability (AUC=0.75 [95% CI: 0.56-0.94]). CONCLUSIONS ONSD and TCD methods demonstrated agreement with invasively-monitored ICP, suggesting their potential roles in the detection of intracranial hypertension in HIBI after cardiac arrest.
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Affiliation(s)
- Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada,.
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada,; Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada,; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Philip N Ainslie
- Department of Health and Exercise Sciences, The University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS San Martino, Genova, Italy
| | - Leanne Calviello
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada
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45
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Streijger F, So K, Manouchehri N, Gheorghe A, Okon EB, Chan RM, Ng B, Shortt K, Sekhon MS, Griesdale DE, Kwon BK. A Direct Comparison between Norepinephrine and Phenylephrine for Augmenting Spinal Cord Perfusion in a Porcine Model of Spinal Cord Injury. J Neurotrauma 2018; 35:1345-1357. [PMID: 29338544 DOI: 10.1089/neu.2017.5285] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Current clinical guidelines recommend elevating the mean arterial blood pressure (MAP) to increase spinal cord perfusion in patients with acute spinal cord injury (SCI). This is typically achieved with vasopressors such as norepinephrine (NE) and phenylephrine (PE). These drugs differ in their pharmacological properties and potentially have different effects on spinal cord blood flow (SCBF), oxygenation (PO2), and downstream metabolism after injury. Using a porcine model of thoracic SCI, we evaluated how these vasopressors influenced intraparenchymal SCBF, PO2, hydrostatic pressure, and metabolism within the spinal cord adjacent to the injury site. Yorkshire pigs underwent a contusion/compression SCI at T10 and were randomized to receive either NE or PE for MAP elevation of 20 mm Hg, or no MAP augmentation. Prior to injury, a combined SCBF/PO2 sensor, a pressure sensor, and a microdialysis probe were inserted into the spinal cord adjacent to T10 at two locations: a "proximal" site and a "distal" site, 2 mm and 22 mm from the SCI, respectively. At the proximal site, NE and PE resulted in little improvement in SCBF during cord compression. Following decompression, NE resulted in increased SCBF and PO2, whereas decreased levels were observed for PE. However, both NE and PE were associated with a gradual decrease in the lactate to pyruvate (L/P) ratio after decompression. PE was associated with greater hemorrhage through the injury site than that in control animals. Combined, our results suggest that NE promotes better restoration of blood flow and oxygenation than PE in the traumatically injured spinal cord, thus providing a physiological rationale for selecting NE over PE in the hemodynamic management of acute SCI.
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Affiliation(s)
- Femke Streijger
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Kitty So
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Neda Manouchehri
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Ana Gheorghe
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Elena B Okon
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Ryan M Chan
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Benjamin Ng
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Katelyn Shortt
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Mypinder S Sekhon
- 2 Vancouver General Hospital, Division of Critical Care Medicine, Department of Medicine, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Donald E Griesdale
- 3 Department of Anesthesiology, University of British Columbia (UBC) , Vancouver, British Columbia, Canada
| | - Brian K Kwon
- 1 International Collaboration on Repair Discoveries, University of British Columbia (UBC) , Vancouver, British Columbia, Canada .,4 Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia , Vancouver, British Columbia, Canada
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Brugniaux JV, Coombs GB, Barak OF, Dujic Z, Sekhon MS, Ainslie PN. Highs and lows of hyperoxia: physiological, performance, and clinical aspects. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1-R27. [PMID: 29488785 DOI: 10.1152/ajpregu.00165.2017] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Molecular oxygen (O2) is a vital element in human survival and plays a major role in a diverse range of biological and physiological processes. Although normobaric hyperoxia can increase arterial oxygen content ([Formula: see text]), it also causes vasoconstriction and hence reduces O2 delivery in various vascular beds, including the heart, skeletal muscle, and brain. Thus, a seemingly paradoxical situation exists in which the administration of oxygen may place tissues at increased risk of hypoxic stress. Nevertheless, with various degrees of effectiveness, and not without consequences, supplemental oxygen is used clinically in an attempt to correct tissue hypoxia (e.g., brain ischemia, traumatic brain injury, carbon monoxide poisoning, etc.) and chronic hypoxemia (e.g., severe COPD, etc.) and to help with wound healing, necrosis, or reperfusion injuries (e.g., compromised grafts). Hyperoxia has also been used liberally by athletes in a belief that it offers performance-enhancing benefits; such benefits also extend to hypoxemic patients both at rest and during rehabilitation. This review aims to provide a comprehensive overview of the effects of hyperoxia in humans from the "bench to bedside." The first section will focus on the basic physiological principles of partial pressure of arterial O2, [Formula: see text], and barometric pressure and how these changes lead to variation in regional O2 delivery. This review provides an overview of the evidence for and against the use of hyperoxia as an aid to enhance physical performance. The final section addresses pathophysiological concepts, clinical studies, and implications for therapy. The potential of O2 toxicity and future research directions are also considered.
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Affiliation(s)
| | - Geoff B Coombs
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada
| | - Otto F Barak
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Zeljko Dujic
- Department of Integrative Physiology, School of Medicine, University of Split , Split , Croatia
| | - Mypinder S Sekhon
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada.,Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia , Vancouver, British Columbia , Canada
| | - Philip N Ainslie
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada
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Abstract
Secondary injury is a major determinant of outcome in hypoxic ischemic brain injury (HIBI) after cardiac arrest and may be mitigated by optimizing cerebral oxygen delivery (CDO2). CDO2 is determined by cerebral blood flow (CBF), which is dependent upon mean arterial pressure (MAP). In health, CBF remains constant over the MAP range through cerebral autoregulation. In HIBI, the zone of intact cerebral autoregulation is narrowed and varies for each patient. Maintaining MAP within the intact autoregulation zone may mitigate ischemia, hyperemia and secondary injury. The optimal MAP in individual patients can be determined using real time autoregulation monitoring techniques.
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Affiliation(s)
- Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada. .,Critical Care Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Donald E Griesdale
- Department of Medicine, Division of Critical Care Medicine, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada.,Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 899 West 12th Avenue, University of British Columbia, Vancouver, BC, V5Z 1M9, Canada
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48
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Abstract
Hypoxic ischemic brain injury (HIBI) after cardiac arrest (CA) is a leading cause of mortality and long-term neurologic disability in survivors. The pathophysiology of HIBI encompasses a heterogeneous cascade that culminates in secondary brain injury and neuronal cell death. This begins with primary injury to the brain caused by the immediate cessation of cerebral blood flow following CA. Thereafter, the secondary injury of HIBI takes place in the hours and days following the initial CA and reperfusion. Among factors that may be implicated in this secondary injury include reperfusion injury, microcirculatory dysfunction, impaired cerebral autoregulation, hypoxemia, hyperoxia, hyperthermia, fluctuations in arterial carbon dioxide, and concomitant anemia.Clarifying the underlying pathophysiology of HIBI is imperative and has been the focus of considerable research to identify therapeutic targets. Most notably, targeted temperature management has been studied rigorously in preventing secondary injury after HIBI and is associated with improved outcome compared with hyperthermia. Recent advances point to important roles of anemia, carbon dioxide perturbations, hypoxemia, hyperoxia, and cerebral edema as contributing to secondary injury after HIBI and adverse outcomes. Furthermore, breakthroughs in the individualization of perfusion targets for patients with HIBI using cerebral autoregulation monitoring represent an attractive area of future work with therapeutic implications.We provide an in-depth review of the pathophysiology of HIBI to critically evaluate current approaches for the early treatment of HIBI secondary to CA. Potential therapeutic targets and future research directions are summarized.
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Affiliation(s)
- Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada. .,Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada.
| | - Philip N Ainslie
- Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Room 2438, Jim Pattison Pavilion, 2nd Floor, 855 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 899 West 12th Avenue, Vancouver, BC V5Z 1M9, Canada
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Wormsbecker A, Sekhon MS, Griesdale DE, Wiskar K, Rush B. The association between anemia and neurological outcome in hypoxic ischemic brain injury after cardiac arrest. Resuscitation 2017; 112:11-16. [DOI: 10.1016/j.resuscitation.2016.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
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Robba C, Donnelly J, Bertuetti R, Cardim D, Sekhon MS, Aries M, Smielewski P, Richards H, Czosnyka M. Doppler Non-invasive Monitoring of ICP in an Animal Model of Acute Intracranial Hypertension. Neurocrit Care 2016; 23:419-26. [PMID: 26268137 DOI: 10.1007/s12028-015-0163-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In many neurological diseases, intracranial pressure (ICP) is elevated and needs to be actively managed. ICP is typically measured with an invasive transducer, which carries risks. Non-invasive techniques for monitoring ICP (nICP) have been developed. The aim of this study was to compare three different methods of transcranial Doppler (TCD) assessment of nICP in an animal model of acute intracranial hypertension. METHODS In 28 rabbits, ICP was increased to 70-80 mmHg by infusion of Hartmann's solution into the lumbar subarachnoid space. Doppler flow velocity in the basilar artery was recorded. nICP was assessed through three different methods: Gosling's pulsatility index PI (gPI), Aaslid's method (AaICP), and a method based on diastolic blood flow velocity (FVdICP). RESULTS We found a significant correlation between nICP and ICP when all infusion experiments were combined (FVdICP: r = 0.77, AaICP: r = 0.53, gPI: r = 0.54). The ability to distinguish between raised and 'normal' values of ICP was greatest for FVdICP (AUC 0.90 at ICP >40 mmHg). When infusion experiments were considered independently, FVdICP demonstrated again the strongest correlation between changes in ICP and changes in nICP (mean r = 0.85). CONCLUSIONS TCD-based methods of nICP monitoring are better at detecting changes of ICP occurring in time, rather than absolute prediction of ICP as a number. Of the studied methods of nICP, the method based on FVd is best to discriminate between raised and 'normal' ICP and to monitor relative changes of ICP.
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Affiliation(s)
- Chiara Robba
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University, Cambridge University Hospitals Trust, Box 1, Hills Road, Cambridge, CB2 0QQ, UK.
| | - Joseph Donnelly
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Rita Bertuetti
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University, Cambridge University Hospitals Trust, Box 1, Hills Road, Cambridge, CB2 0QQ, UK
| | - Danilo Cardim
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, Vancouver General Hospital, University of British Columbia, West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Marcel Aries
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Hugh Richards
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ, UK
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