1
|
Pardo AC, Carrasco M, Wintermark P, Nunes D, Chock VY, Sen S, Wusthoff CJ. Neuromonitoring practices for neonates with congenital heart disease: a scoping review. Pediatr Res 2024:10.1038/s41390-024-03484-x. [PMID: 39183308 DOI: 10.1038/s41390-024-03484-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024]
Abstract
Neonates with congenital heart disease (CHD) are at risk for adverse neurodevelopmental outcomes. This scoping review summarizes neuromonitoring methods in neonates with CHD. We identified 84 studies investigating the use of near-infrared spectroscopy (NIRS) (n = 37), electroencephalography (EEG) (n = 20), amplitude-integrated electroencephalography (aEEG) (n = 10), transcranial Doppler sonography (TCD) (n = 6), and multimodal monitoring (n = 11). NIRS was used to evaluate cerebral oxygenation, identify risk thresholds and adverse events in the intensive care unit (ICU), and outcomes. EEG was utilized to screen for seizures and to predict adverse outcomes. Studies of aEEG have focused on characterizing background patterns, detecting seizures, and outcomes. Studies of TCD have focused on correlation with short-term clinical outcomes. Multimodal monitoring studies characterized cerebral physiologic dynamics. Most of the studies were performed in single centers, had a limited number of neonates (range 3-183), demonstrated variability in neuromonitoring practices, and lacked standardized approaches to neurodevelopmental testing. We identified areas of improvement for future research: (1) large multicenter studies to evaluate developmental correlates of neuromonitoring practices; (2) guidelines to standardize neurodevelopmental testing methodologies; (3) research to address geographic variation in resource utilization; (4) integration and synchronization of multimodal monitoring; and (5) research to establish a standardized framework for neuromonitoring techniques across diverse settings. IMPACT: This scoping review summarizes the literature regarding neuromonitoring practices in neonates with congenital heart disease (CHD). The identification of low cerebral oxygenation thresholds with NIRS may be used to identify neonates at risk for adverse events in the ICU or adverse neurodevelopmental outcomes. Postoperative neuromonitoring with continuous EEG screening for subclinical seizures and status epilepticus, allow for early and appropriate therapy. Future studies should focus on enrolling larger multicenter cohorts of neonates with CHD with a standardized framework of neuromonitoring practices in this population. Postoperative neurodevelopmental testing should utilize standard assessments and testing intervals.
Collapse
Affiliation(s)
- Andrea C Pardo
- Department of Pediatrics (Neurology and Epilepsy). Northwestern University Feinberg School of Medicine, Chicago, IL, US.
| | - Melisa Carrasco
- Department of Neurology. University of Wisconsin School of Medicine and Public Health, Madison, WI, US
| | - Pia Wintermark
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, Montreal, Qc, Canada
| | - Denise Nunes
- Galter Health Sciences Library. Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Valerie Y Chock
- Department of Pediatrics (Neonatology), Lucile Packard Children's Hospital and Stanford University, Palo Alto, CA, US
| | - Shawn Sen
- Department of Pediatrics (Neonatology). Northwestern University Feinberg School of Medicine, Chicago, IL, US
- Department of Pediatrics, University of California Irvine, Orange, CA, US
| | | |
Collapse
|
2
|
Leon RL, Bitar L, Sharma K, Mir IN, Chalak LF. Postnatal Cerebral Hemodynamics and Placental Vascular Malperfusion Lesions in Neonates With Congenital Heart Disease. Pediatr Neurol 2024; 156:72-78. [PMID: 38733857 PMCID: PMC11269165 DOI: 10.1016/j.pediatrneurol.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 02/11/2024] [Accepted: 03/31/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Neonates with congenital heart disease (CHD) have smaller brain volume at birth. High rates of placental vascular malperfusion lesions may play a role in disrupted brain development. METHODS This is a single-center retrospective cohort study of infants born between 2010 and 2019 who were diagnosed with a major cardiac defect requiring surgery in the first year of life. Doppler ultrasound RI of the middle cerebral artery (MCA) and anterior cerebral artery were calculated within the first 72 hours of life. Placentas were evaluated using a standardized approach. RESULTS Over the study period, there were 52 patients with hypoplastic left heart syndrome (HLHS), 22 with single-ventricle right ventricular outflow tract obstruction (SV-RVOTO), 75 with a two-ventricle cardiac defect (2V), and 25 with transposition of the great arteries (TGA). MCA Doppler RI were significantly higher for all subgroups of CHD compared with control subjects (0.68 ± 0.11 in control subjects compared with 0.78 ± 0.13 in HLHS, P = 0.03; 0.77 ± 0.10 in SV-RVOTO, P = 0.002; 0.78 ± 0.13 in 2V, P = 0.03; and 0.80 ± 0.14 in TGA; P = 0.001) with the highest average MCA RI in the TGA group. In subgroup analyses, placental fetal vascular malperfusion in the 2V group was associated with higher MCA RI, but this relationship was not present in other subgroups, nor in regards to maternal vascular malperfusion. CONCLUSIONS Major forms of CHD are associated with significantly higher cerebral artery RI postnatally, but placental vascular malperfusion lesions may not contribute to this hemodynamic adaptation.
Collapse
Affiliation(s)
- Rachel L Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Lynn Bitar
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kavita Sharma
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Imran N Mir
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
3
|
De Silvestro A, Natalucci G, Feldmann M, Hagmann C, Nguyen TD, Coraj S, Jakab A, Kottke R, Latal B, Knirsch W, Tuura R. Effects of hemodynamic alterations and oxygen saturation on cerebral perfusion in congenital heart disease. Pediatr Res 2024:10.1038/s41390-024-03106-6. [PMID: 38438551 DOI: 10.1038/s41390-024-03106-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Patients with severe congenital heart disease (CHD) are at risk for neurodevelopmental impairment. An abnormal cerebral blood supply caused by the altered cardiac physiology may limit optimal brain development. The aim of this study was to evaluate the effect of a systemic-to-pulmonary shunt, aortic arch obstruction and arterial oxygen saturation on cerebral perfusion in patients with severe CHD. METHODS Patients with severe CHD requiring cardiac surgery within the first six weeks of life, who underwent pre- and/or postoperative brain magnetic resonance imaging (MRI), and healthy controls with one postnatal scan were included. Cerebral perfusion in deep and cortical gray matter was assessed by pseudocontinuous arterial spin labeling MRI. RESULTS We included 59 CHD and 23 healthy control scans. The presence of a systemic-to-pulmonary shunt was associated with decreased perfusion in cortical (p = 0.003), but not in deep gray matter (p = 0.031). No evidence for an effect of aortic arch obstruction and arterial oxygen saturation on cerebral perfusion was found. After adjusting for hemodynamic and oxygen saturation parameters, deep (p = 0.018) and cortical (p = 0.012) gray matter perfusion was increased in patients with CHD compared to controls. CONCLUSION We detected regional differences in compensation to the cerebral steal effect in patients with severe CHD. IMPACT Patients with severe congenital heart disease (CHD) have altered postnatal brain hemodynamics. A systemic-to-pulmonary shunt was associated with decreased perfusion in cortical gray matter but preserved perfusion in deep gray matter, pointing towards regional differences in compensation to the cerebral steal effect. No effects of aortic arch obstruction and arterial oxygenation on cerebral perfusion were seen. Cerebral perfusion was increased in patients with CHD compared to healthy controls after adjusting for hemodynamic alterations and oxygen saturation. To improve neuroprotection and neurodevelopmental outcomes, it is important to increase our understanding of the factors influencing cerebral perfusion in neonates with severe CHD.
Collapse
Affiliation(s)
- Alexandra De Silvestro
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Center for MR-Research, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Giancarlo Natalucci
- University of Zurich, Zurich, Switzerland
- Larsson-Rosenquist Foundation Center for Neurodevelopment, Growth and Nutrition of the Newborn, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
- Newborn Research Zurich, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Maria Feldmann
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cornelia Hagmann
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Thi Dao Nguyen
- University of Zurich, Zurich, Switzerland
- Newborn Research Zurich, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Seline Coraj
- University of Zurich, Zurich, Switzerland
- Larsson-Rosenquist Foundation Center for Neurodevelopment, Growth and Nutrition of the Newborn, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
- Newborn Research Zurich, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Andras Jakab
- Center for MR-Research, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Raimund Kottke
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Department of Diagnostic Imaging, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
- Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Walter Knirsch
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Ruth Tuura
- Center for MR-Research, University Children's Hospital Zurich, Zurich, Switzerland.
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
| |
Collapse
|
4
|
De Silvestro AA, Kellenberger CJ, Gosteli M, O'Gorman R, Knirsch W. Postnatal cerebral hemodynamics in infants with severe congenital heart disease: a scoping review. Pediatr Res 2023; 94:931-943. [PMID: 36944722 PMCID: PMC10444615 DOI: 10.1038/s41390-023-02543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/08/2023] [Accepted: 02/08/2023] [Indexed: 03/23/2023]
Abstract
Patients with severe congenital heart disease (CHD) are at risk for impaired neurodevelopment. Cerebral blood supply may be diminished by congenital anomalies of cardiovascular anatomy and myocardial function. The aim of this scoping review was to summarize the current knowledge on cerebral hemodynamics in infants with severe CHD. A scoping review was performed. Five databases were searched for articles published from 01/1990 to 02/2022 containing information on cerebral hemodynamics assessed by neuroimaging methods in patients with severe CHD within their first year of life. A total of 1488 publications were identified, of which 26 were included. Half of the studies used Doppler ultrasound, and half used magnetic resonance imaging techniques. Studies focused on preoperative findings of cerebral hemodynamics, effects of surgical and conservative interventions, as well as on associations between cerebral hemodynamics and brain morphology or neurodevelopment. Cerebral perfusion was most severely affected in patients with single ventricle and other cyanotic disease. Neuroimaging methods provide a large variety of information on cerebral hemodynamics. Nevertheless, small and heterogeneous cohorts complicate this field of research. Further studies are needed to improve our understanding of the link between CHD and altered cerebral hemodynamics to optimize neuroprotection strategies. IMPACT: Postnatal cerebral hemodynamics are altered in infants with congenital heart disease (CHD) as compared to healthy controls, especially in most severe types such as single ventricle or other cyanotic CHD. Associations of these alterations with brain volume and maturation reveal their clinical relevance. Research in this area is limited due to the rarity and heterogeneity of diagnoses. Furthermore, longitudinal studies have rarely been conducted. Further effort is needed to better understand the deviation from physiological cerebral perfusion and its consequences in patients with CHD to optimize neuroprotection strategies.
Collapse
Affiliation(s)
- Alexandra Angela De Silvestro
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Center for MR-Research, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christian Johannes Kellenberger
- Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Diagnostic Imaging, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martina Gosteli
- University Library, University of Zurich, Zurich, Switzerland
| | - Ruth O'Gorman
- Center for MR-Research, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Walter Knirsch
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland.
- Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland.
| |
Collapse
|
5
|
Sun L, Zhang K, Chen H, Ji W, Huang Y, Zhang M, Zheng J. Age-Related Changes in Cerebral Hemodynamics in Children Undergoing Congenital Cardiac Surgery: A Prospective Observational Study. J Cardiothorac Vasc Anesth 2021; 36:1617-1624. [PMID: 34588126 DOI: 10.1053/j.jvca.2021.08.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/05/2021] [Accepted: 08/27/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To explore age-related cerebral hemodynamic characteristics before and after pediatric cardiac surgery. DESIGN Prospective observational study. SETTING Single-center study based at a tertiary care center in Shanghai, China. PATIENTS Fifty-three children with congenital heart disease (CHD) aged zero-to-six years undergoing cardiac surgery with cardiopulmonary bypass were enrolled, and 44 children finally were analyzed. INTERVENTION Cerebral hemodynamics were measured by transcranial color-coded duplex sonography in the right temporal window before and after surgery. The resistance index (RI), pulsatility index (PI), and cerebral blood flow velocity (CBFV), including time average maximum flow velocity (Vtamax), mean blood flow velocity (Vmean), and the peak systolic flow velocity (Vpeak), of the right middle cerebral artery (MCA) and regional cerebral oxygen saturation (rScO2) of the right frontal lobe were measured and analyzed. Heart rate and mean arterial pressure were also recorded during ultrasound. MEASUREMENTS AND MAIN RESULTS RI and PI decreased exponentially with age before and after cardiac surgery. While PI remained unchanged after cardiac surgery, RI was significantly reduced. Furthermore, RI reduction after cardiac surgery was more significant in children >18 months compared to those ≤18 months. CBFV of the right MCA also showed exponential increase with age, but rScO2 linearly increased. Cardiac surgery significantly changed the cerebral hemodynamics, but it did not affect rScO2 in children regardless of age. CONCLUSIONS Age-related cerebral hemodynamic changes exist in children with CHD. Cardiopulmonary bypass surgery led to greater cerebrovascular dilation in children aged ≤18 months than those >18 months.
Collapse
Affiliation(s)
- Liping Sun
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kan Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hualin Chen
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Ji
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yue Huang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mazhong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Pediatric Clinical Pharmacology Laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| |
Collapse
|
6
|
O'Brien NF, Reuter-Rice K, Wainwright MS, Kaplan SL, Appavu B, Erklauer JC, Ghosh S, Kirschen M, Kozak B, Lidsky K, Lovett ME, Mehollin-Ray AR, Miles DK, Press CA, Simon DW, Tasker RC, LaRovere KL. Practice Recommendations for Transcranial Doppler Ultrasonography in Critically Ill Children in the Pediatric Intensive Care Unit: A Multidisciplinary Expert Consensus Statement. J Pediatr Intensive Care 2021; 10:133-142. [PMID: 33884214 PMCID: PMC8052112 DOI: 10.1055/s-0040-1715128] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
Transcranial Doppler ultrasonography (TCD) is being used in many pediatric intensive care units (PICUs) to aid in the diagnosis and monitoring of children with known or suspected pathophysiological changes to cerebral hemodynamics. Standardized approaches to scanning protocols, interpretation, and documentation of TCD examinations in this setting are lacking. A panel of multidisciplinary clinicians with expertise in the use of TCD in the PICU undertook a three-round modified Delphi process to reach unanimous agreement on 34 statements and then create practice recommendations for TCD use in the PICU. Use of these recommendations will help to ensure that high quality TCD images are captured, interpreted, and reported using standard nomenclature. Furthermore, use will aid in ensuring reproducible and meaningful study results between TCD practitioners and across PICUs.
Collapse
Affiliation(s)
- Nicole Fortier O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Karin Reuter-Rice
- Department of Pediatrics, Division of Pediatric Critical Care, School of Medicine, School of Nursing, Duke University, Duke Institute for Brain Sciences, North Carolina, United States
| | - Mark S. Wainwright
- Department of Neurology, University of Washington, Seattle Children's Hospital, Washington, United States
| | - Summer L. Kaplan
- Department of Radiology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brian Appavu
- Department of Pediatrics, Division of Critical Care Medicine, Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine—Phoenix, Arizona, United States
| | - Jennifer C. Erklauer
- Department of Pediatrics, Division of Critical Care Medicine and Neurology, Baylor College of Medicine, Texas Children's Hospital, Texas, United States
| | - Suman Ghosh
- Department of Pediatrics, Division of Pediatric Neurology, University of Florida, College of Medicine, Florida, United States
| | - Matthew Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Brandi Kozak
- Department of Radiology, Ultrasound Division, Center for Pediatric Contrast Ultrasound, The Children's Hospital of Philadelphia, Pennsylvania, United States
| | - Karen Lidsky
- Department of Pediatrics, Division of Pediatric Critical Care, Wolfson Children's Hospital, University of Florida, Florida, United States
| | - Marlina Elizabeth Lovett
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University, Ohio, United States
| | - Amy R. Mehollin-Ray
- Department of Radiology, Baylor College of Medicine, E.B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Texas, United States
| | - Darryl K. Miles
- Department of Pediatrics/Division of Critical Care, UT Southwestern Medical Center, Texas, United States
| | - Craig A. Press
- Department of Pediatrics, Section of Child Neurology, University of Colorado, Children's Hospital Colorado, Colorado, United States
| | - Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pennsylvania, United States
| | - Robert C. Tasker
- Departments of Neurology & Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
| | - Kerri Lynn LaRovere
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Massachusetts, United States
| |
Collapse
|
7
|
Zhang W, Xie S, Han D, Ou-Yang C, Lu J, Huang J. Effect of End-Tidal Carbon Dioxide on Cerebral Dynamics in Infants With Ventricular Septal Defect: A Comparison Between Sevoflurane and Intravenous Anesthetics. J Cardiothorac Vasc Anesth 2020; 34:1558-1564. [PMID: 32139343 DOI: 10.1053/j.jvca.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary aim was to compare the changes in regional cerebral oxygen saturation (rSO2) and cerebral blood flow velocity (CBFV) during sevoflurane and intravenous anesthesia when the end-tidal carbon dioxide partial pressure (PETCO2) changed in infants undergoing ventricular septal defect (VSD) repair. DESIGN Prospective, observational study. SETTING Tertiary care hospital. PARTICIPANTS Patients younger than 6 months with VSDs. INTERVENTIONS End-tidal carbon dioxide was increased by decreasing tidal volume or respiratory rate. MEASUREMENTS AND MAIN RESULTS The infants were randomly assigned to receive either sevoflurane (SA group) or midazolam-sufentanil based intravenous anesthesia (IA group). PETCO2 levels of 30 mmHg (T1), 35 mmHg (T2), 40 mmHg (T3), or 45 mmHg (T4) were obtained by adjusting the tidal volume and respiratory rate. There were no significant intergroup differences in rSO2. In the SA group, as PETCO2 increased from T1 to T4, rSO2 increased significantly from 68.8% ± 5.9% to 76.4% ± 6.0% (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). In the IA group, rSO2 showed a significant increase from 68.6% ± 4.6% to 76.1% ± 6.2% with the change in PETCO2 from T1 to T4 (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). CONCLUSION Cerebrovascular response to different PETCO2 levels was preserved and similar during clinically relevant doses of sevoflurane anesthesia and midazolam-sufentanil based intravenous anesthesia in infants younger than 6 months old undergoing VSD repair.
Collapse
Affiliation(s)
- Weizhi Zhang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Siyuan Xie
- Anesthesia Department, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Ding Han
- Anesthesia Department, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Chuan Ou-Yang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
| |
Collapse
|
8
|
Effects of relative low minute ventilation on cerebral haemodynamics in infants undergoing ventricular septal defect repair. Cardiol Young 2020; 30:205-212. [PMID: 31937383 DOI: 10.1017/s1047951119003135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Ventilation-associated changes in blood carbon dioxide levels are associated with various physiological changes in infants undergoing surgery. Studies on the effects of mechanical ventilation on cerebral haemodynamics especially for infants with CHD are scarce. AIM This study was done to compare the changes in regional cerebral oxygen saturation and cerebral blood flow velocity when the end-tidal carbon dioxide partial pressure changed during different minute ventilation settings in infants undergoing ventricular septal defect repair. METHODS A total of 67 patients less than 1 year old with ventricular septal defect were enrolled, and 65 patients (age: 6.7 ± 3.4 months, weight: 6.4 ± 1.5 kg) were studied. After anaesthesia induction and endotracheal intubation, the same mechanical ventilation mode (The fraction of inspired oxygen was 50%, and the inspiratory-to-expiratory ratio was 1:1.5.) was adopted. The end-tidal carbon dioxide partial pressure of 30 mmHg (T1), 35 mmHg (T2), 40 mmHg (T3), or 45 mmHg (T4) were obtained, respectively, by adjusting tidal volume and respiratory rate. Minute ventilation per kilogram was calculated by the formula: minute ventilation per kilogram = tidal volume * respiratory rate/kg. Regional cerebral oxygen saturation was monitored by real-time near-infrared spectroscopy. Cerebral blood flow velocity (systolic flow velocity, end-diastolic flow velocity, and mean flow velocity), pulsatility index, and resistance index were measured intermittently by transcranial Doppler. Systolic pressure, diastolic pressure, stroke volume index, and cardiac index were recorded using the pressure recording analytical method. RESULTS As the end-tidal carbon dioxide partial pressure increased from 30 to 45 mmHg, regional cerebral oxygen saturation increased significantly from 69 ± 5% to 79 ± 4% (p < 0.001). Cerebral blood flow velocity (systolic flow velocity, end-diastolic flow velocity, and mean flow velocity) increased linearly, while pulsatility index and resistance index decreased linearly from T1 (systolic flow velocity, 84 ± 19 cm/second; end-diastolic flow velocity, 14 ± 4 cm/second; mean flow velocity, 36 ± 10 cm/second; pulsatility index, 2.13 ± 0.59; resistance index, 0.84 ± 0.12) to T4 (systolic flow velocity, 113 ± 22 cm/second; end-diastolic flow velocity, 31 ± 6 cm/second; mean flow velocity, 58 ± 11 cm/second; pulsatility index, 1.44 ± 0.34; resistance index, 0.72 ± 0.07) (p < 0.001). There were significant differences in changes of systolic flow velocity, end-diastolic flow velocity, mean flow velocity, pulsatility index, and resistance index as the end-tidal carbon dioxide partial pressure increased from 30 to 45 mmHg between subgroups of infants ≤6 and infants >6 months, while the changes of regional cerebral oxygen saturation between subgroups were not statistically different. Regional cerebral oxygen saturation and cerebral blood flow velocity (systolic flow velocity, end-diastolic flow velocity, and mean flow velocity) were negatively correlated with minute ventilation per kilogram (r = -0.538, r = -0.379, r = -0.504, r = -0.505, p < 0.001). Pulsatility index and resistance index were positively related to minute ventilation per kilogram (r = 0.464, r = 0.439, p < 0.001). The diastolic pressure was significantly reduced from T1 (41 ± 7 mmHg) to T4 (37 ± 6 mmHg) (p < 0.001). There were no significant differences in systolic pressure, stroke volume index, and cardiac index with the change of end-tidal carbon dioxide partial pressure from T1 to T4 (p = 0.063, p = 0.382, p = 0.165, p > 0.05). CONCLUSION A relative low minute ventilation strategy increases regional cerebral oxygen saturation and cerebral blood flow, which may improve cerebral oxygenation and brain perfusion in infants undergoing ventricular septal defect repair.
Collapse
|
9
|
Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers. Pediatr Crit Care Med 2020; 21:67-74. [PMID: 31568242 DOI: 10.1097/pcc.0000000000002118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. DESIGN Electronic-mail recruitment with survey of expert centers using web-based questionnaire. SETTING Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. CONCLUSIONS At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices.
Collapse
|