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Tawakul A, Alluqmani MM, Badawi AS, Alawfi AK, Alharbi EK, Aljohani SA, Mogharbel GH, Alahmadi HA, Khawaji ZY. Risk Factors for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review of Observational Studies. Neurocrit Care 2024:10.1007/s12028-024-02059-2. [PMID: 39048760 DOI: 10.1007/s12028-024-02059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024]
Abstract
Cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) remains one of the leading causes of high mortality and poor outcomes. Understanding the risk factors associated with CV is pivotal to improving patients' outcomes. We conducted an extensive search for analytical observational studies that analyzed the correlation between various variables and the likelihood of CV development among adult patients with SAH (age ≥ 18 years). Five scholar databases were used, namely, PubMed, EBSCO, Web of Science, Science Direct, and Google Scholar. Relevant studies published between January 1st, 2016, and August 9th, 2023, were included. The Newcastle-Ottawa Scale was adopted to assess the risk of bias among included observational studies. A total of 33 studies met the inclusion criteria. Of the 24,958 patients with SAH who were identified, 6,761 patients had a subsequent CV (27.1%). Several statistically significant risk factors were reported across the literature. Younger age, female sex, smoking, alcohol intake, modified Fisher grade 3-4, higher Hunt and Hess grading, and the presence of multiple comorbidities (diabetes, hypertension, congestive heart failure, and history of stroke) were among the well-established risk factors for CV. Additionally, leukocytosis was consistently reported to be a significant predictor in multiple studies, providing compelling evidence for its association with CV. Even though single studies reported an association between CV and certain variables, further research is necessary to investigate the implications of these findings. These include arterial tortuosity, hypokalemia, potassium to glucose gradient, hypoalbuminemia, anemia, von Willebrand factor and vascular endothelial growth factor, use of desflurane, and hemodynamic stability. Overall, this systemic review provides a comprehensive summary of the current data that evaluates the potential risk factors for the development of CV after SAH. However, because of data heterogeneity, certain factors require further validation in their correlation with CV development. Larger-scale observational and clinical trials are mandatory to extensively investigate the significant predictors of CV to lay the scientific foundation for improving outcomes in susceptible patients with SAH.
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Affiliation(s)
- Abdullah Tawakul
- Department of Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Majed Mohammedali Alluqmani
- Department of Neurology and Neuroimmunology and Neuroinflammatory, Demyelinating Disease, College of Medicine, Taibah University, Madinah, Saudi Arabia
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Robba C, Battaglini D, Cinotti R, Asehnoune K, Stevens R, Taccone FS, Badenes R, Pelosi P. Individualized Thresholds of Hypoxemia and Hyperoxemia and their Effect on Outcome in Acute Brain Injured Patients: A Secondary Analysis of the ENIO Study. Neurocrit Care 2024; 40:515-528. [PMID: 37322325 DOI: 10.1007/s12028-023-01761-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND In acute brain injury (ABI), the effects of hypoxemia as a potential cause of secondary brain damage and poor outcome are well documented, whereas the impact of hyperoxemia is unclear. The primary aim of this study was to assess the episodes of hypoxemia and hyperoxemia in patients with ABI during the intensive care unit (ICU) stay and to determine their association with in-hospital mortality. The secondary aim was to identify the optimal thresholds of arterial partial pressure of oxygen (PaO2) predicting in-hospital mortality. METHODS We conducted a secondary analysis of a prospective multicenter observational cohort study. Adult patients with ABI (traumatic brain injury, subarachnoid aneurysmal hemorrhage, intracranial hemorrhage, ischemic stroke) with available data on PaO2 during the ICU stay were included. Hypoxemia was defined as PaO2 < 80 mm Hg, normoxemia was defined as PaO2 between 80 and 120 mm Hg, mild/moderate hyperoxemia was defined as PaO2 between 121 and 299 mm Hg, and severe hyperoxemia was defined as PaO2 levels ≥ 300 mm Hg. RESULTS A total of 1,407 patients were included in this study. The mean age was 52 (±18) years, and 929 (66%) were male. Over the ICU stay, the fractions of patients in the study cohort who had at least one episode of hypoxemia, mild/moderate hyperoxemia, and severe hyperoxemia were 31.3%, 53.0%, and 1.7%, respectively. PaO2 values below 92 mm Hg and above 156 mm Hg were associated with an increased probability of in-hospital mortality. Differences were observed among subgroups of patients with ABI, with consistent effects only seen in patients without traumatic brain injury. CONCLUSIONS In patients with ABI, hypoxemia and mild/moderate hyperoxemia were relatively frequent. Hypoxemia and hyperoxemia during ICU stay may influence in-hospital mortality. However, the small number of oxygen values collected represents a major limitation of the study.
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Affiliation(s)
- Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genova, Italy
| | | | - Raphael Cinotti
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
- UMR 1246 SPHERE Methods in Patients-Centered Outcomes and Health Research, University of Nantes, University of Tours, INSERM, Nantes, France
| | - Karim Asehnoune
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
| | - Robert Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
- INCLIVA Research Medical Institute, Valencia, Spain
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genova, Italy
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Zhang S, Ji J, Gao S, Yang S, Song Z, Li J, Liu J. Association between SpO 2 and the risk of death in elderly T2DM patients with cerebral infarction: a retrospective cohort study. Front Neurol 2024; 15:1344000. [PMID: 38533418 PMCID: PMC10964770 DOI: 10.3389/fneur.2024.1344000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
Objective This study aimed to evaluate the SpO2 (transcutaneous oxygen saturation) -mortality link in elderly T2DM (diabetes mellitus type 2) patients with cerebral infarction and identify their optimal SpO2 range. Methods In this investigation, we employed a comprehensive approach. Initially, we screened the MIMIC-IV database, identifying elderly T2DM patients with cerebral infarction, utilizing specific ICD-9 and ICD-10 codes. We then harnessed the power of restricted cubic splines to craft a visual representation of the correlation between SpO2 and 1-year mortality. To enhance our analysis, we harnessed Cox multivariate regression, allowing us to compute adjusted hazard ratios (HR) accompanied by 95% confidence intervals (CIs). Additionally, we crafted Cumulative Mortality Curve analyses, augmenting our study by engaging in rigorous subgroup analyses, stratifying our observations based on pertinent covariates. Results In this study, 448 elderly T2DM patients with cerebral infarction were included. Within 1-year post-discharge, 161 patients (35.94%) succumbed. Employing Restricted Cubic Spline analysis, a statistically significant U-shaped non-linear relationship between admission ICU SpO2 levels and 1-year mortality was observed (P-value < 0.05). Further analysis indicated that both low and high SpO2 levels increased the mortality risk. Cox multivariate regression analysis, adjusting for potential confounding factors, confirmed the association of low (≤94.5%) and high SpO2 levels (96.5-98.5%) with elevated 1-year mortality risk, particularly notably high SpO2 levels (>98.5%) [HR = 2.06, 95% CI: 1.29-3.29, P-value = 0.002]. The cumulative mortality curves revealed the following SpO2 subgroups from high to low cumulative mortality at the 365th day: normal levels (94.5% < SpO2 ≤ 96.5%), low levels (SpO2 ≤ 94.5%), high levels (96.5% < SpO2 ≤ 98.5%), and notably high levels (>98.5%). Subgroup analysis demonstrated no significant interaction between SpO2 and grouping variables, including Sex, Age, Congestive heart failure, Temperature, and ICU length of stay (LOS-ICU; P-values for interaction were >0.05). Conclusions Striking an optimal balance is paramount, as fixating solely on lower SpO2 limits or neglecting high SpO2 levels may contribute to increased mortality rates. To mitigate mortality risk in elderly T2DM patients with cerebral infarction, we recommend maintaining SpO2 levels within the range of 94.5-96.5%.
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Affiliation(s)
- Shuo Zhang
- College of Clinical Medicine, North China University of Science and Technology, Tangshan, China
| | - Jiaqi Ji
- College of Clinical Medicine, North China University of Science and Technology, Tangshan, China
| | - Siqi Gao
- School of Basic Medical Sciences, North China University of Science and Technology, Tangshan, China
| | - Shu Yang
- College of Clinical Medicine, North China University of Science and Technology, Tangshan, China
| | - Zeyi Song
- College of Clinical Medicine, North China University of Science and Technology, Tangshan, China
| | - Jianmin Li
- College of Clinical Medicine, North China University of Science and Technology, Tangshan, China
| | - Junjie Liu
- College of Clinical Medicine, North China University of Science and Technology, Tangshan, China
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Dey A, Khandelwal A. Hyperoxia in neurocritical care: Current perspectives. Med J Armed Forces India 2024; 80:10-15. [PMID: 38239601 PMCID: PMC10793228 DOI: 10.1016/j.mjafi.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/29/2022] [Indexed: 01/18/2023] Open
Abstract
In recent years, a lot of controversies have emerged regarding conservative versus liberal oxygen therapy in critically ill patients. While neurologically injured patients might have higher oxygen demand due to high cerebral metabolism, recent studies have clearly shown that hyperoxia may not be beneficial in improving the neurological outcome in traumatic brain injury, subarachnoid hemorrhage, and acute ischemic stroke. Rather, hyperoxia might worsen neurological outcome in such conditions by various mechanisms like direct cerebral vasoconstriction or by increased excitotoxicity, which in turn leads to lipid peroxidation and generation of harmful reactive oxygen species. This article brings into insight the current evidence on the effect of hyperoxia on these three acute neurological insults.
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Affiliation(s)
- Ankita Dey
- Assistant Professor (Anaesthesia), All India Institute of Medical Sciences (AIIMS), Bathinda, India
| | - Ankur Khandelwal
- Associate Professor (Anaesthesiology, Critical Care & Pain Medicine), All India Institute of Medical Sciences (AIIMS), Guwahati, Assam, India
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Liu X, Irwin DA, Huang C, Gu Y, Chen L, Donohue KD, Chen L, Yu G. A Wearable Fiber-Free Optical Sensor for Continuous Monitoring of Cerebral Blood Flow in Freely Behaving Mice. IEEE Trans Biomed Eng 2023; 70:1838-1848. [PMID: 37015409 PMCID: PMC10542964 DOI: 10.1109/tbme.2022.3229513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Wearable technologies for functional brain monitoring in freely behaving subjects can advance our understanding of cognitive processing and adaptive behavior. Existing technologies are lacking in this capability or need procedures that are invasive and/or otherwise impede brain assessments during social behavioral conditions, exercise, and sleep. METHODS In response a complete system was developed to combine relative cerebral blood flow (rCBF) measurement, O2 and CO2 supplies, and behavior recording for use on conscious, freely behaving mice. An innovative diffuse speckle contrast flowmetry (DSCF) device and associated hardware were miniaturized and optimized for rCBF measurements in small subject applications. The use of this wearable, fiber-free, near-infrared DSCF head-stage/probe allowed no craniotomy, minimally invasive probe implantation, and minimal restraint of the awake animal. RESULTS AND CONCLUSIONS Significant correlations were found between measurements with the new DSCF design and an optical standard. The system successfully detected rCBF responses to CO2-induced hypercapnia in both anesthetized and freely behaving mice. SIGNIFICANCE Collecting rCBF and activity information together during natural behaviors provides realistic physiological results and opens the path to exploring their correlations with pathophysiological conditions.
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Affiliation(s)
- Xuhui Liu
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Daniel A. Irwin
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Chong Huang
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Yutong Gu
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
| | - Li Chen
- Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Kevin D. Donohue
- Department of Electrical and Computer Engineering, University of Kentucky, Lexington, KY, USA
| | - Lei Chen
- Department of Physiology, Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY, USA
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky, Lexington, KY, USA
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Young PJ, Al-Fares A, Aryal D, Arabi YM, Ashraf MS, Bagshaw SM, Mat-Nor MB, Beane A, Borghi G, de Oliveira Manoel AL, Dullawe L, Fazla F, Fujii T, Haniffa R, Hodgson CL, Hunt A, Lawrence C, Mackle D, Mangal K, Nichol AD, Olatunji S, Rashan A, Rashan S, Tomazini B, Kasza J. Protocol and statistical analysis plan for the mega randomised registry trial comparing conservative vs. liberal oxygenation targets in adults with nonhypoxic ischaemic acute brain injuries and conditions in the intensive care unit (Mega-ROX Brains). CRIT CARE RESUSC 2023; 25:53-59. [PMID: 37876994 PMCID: PMC10581272 DOI: 10.1016/j.ccrj.2023.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Background The effect of conservative vs. liberal oxygen therapy on 90-day in-hospital mortality in adults who have nonhypoxic ischaemic encephalopathy acute brain injuries and conditions and are receiving invasive mechanical ventilation in the intensive care unit (ICU) is uncertain. Objective The objective of this study was to summarise the protocol and statistical analysis plan for the Mega-ROX Brains trial. Design setting and participants Mega-ROX Brains is an international randomised clinical trial, which will be conducted within an overarching 40,000-participant, registry-embedded clinical trial comparing conservative and liberal ICU oxygen therapy regimens. We expect to enrol between 7500 and 9500 participants with nonhypoxic ischaemic encephalopathy acute brain injuries and conditions who are receiving unplanned invasive mechanical ventilation in the ICU. Main outcome measures The primary outcome is in-hospital all-cause mortality up to 90 d from the date of randomisation. Secondary outcomes include duration of survival, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and the proportion of participants discharged home. Results and conclusions Mega-ROX Brains will compare the effect of conservative vs. liberal oxygen therapy regimens on 90-day in-hospital mortality in adults in the ICU with acute brain injuries and conditions. The protocol and planned analyses are reported here to mitigate analysis bias. Trial Registration Australian and New Zealand Clinical Trials Registry (ACTRN 12620000391976).
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Affiliation(s)
- Paul J. Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Abdulrahman Al-Fares
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Respiratory and Cardiac Failure, Ministry of Health, Kuwait
| | - Diptesh Aryal
- Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, And Intensive Care Department, King Abdulaziz Medical City, Ministry of National-Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Sean M. Bagshaw
- Department of Critical Care Medicine, University of Alberta, And the Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mohd Basri Mat-Nor
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
| | - Abigail Beane
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
| | - Giovanni Borghi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Layoni Dullawe
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
| | - Fathima Fazla
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
| | - Rashan Haniffa
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College Hospital, London, UK
| | - Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Anna Hunt
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Cassie Lawrence
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kishore Mangal
- Department of Critical Care Medicine, Fortis Escorts Hospital, Jaipur, India
| | - Alistair D. Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- School of Medicine and Medical Sciences, University College Dublin, Ireland
- Department of Anaesthesia and Intensive Care, St Vincent's Hospital, Dublin, Ireland
| | - Shaanti Olatunji
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Aasiyah Rashan
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- University College London, Institute of Health Informatics, London, UK
| | - Sumayyah Rashan
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Bruno Tomazini
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network – BricNet, Brazil
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - for the Mega-ROX management committee
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Respiratory and Cardiac Failure, Ministry of Health, Kuwait
- Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, And Intensive Care Department, King Abdulaziz Medical City, Ministry of National-Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Anesthesia and Critical Care Unit, Lady Reading Hospital, Peshawar, Pakistan
- Department of Critical Care Medicine, University of Alberta, And the Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Critical Care Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College Hospital, London, UK
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Critical Care Medicine, Fortis Escorts Hospital, Jaipur, India
- School of Medicine and Medical Sciences, University College Dublin, Ireland
- Department of Anaesthesia and Intensive Care, St Vincent's Hospital, Dublin, Ireland
- University College London, Institute of Health Informatics, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network – BricNet, Brazil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - the Australian and New Zealand Intensive Care Society Clinical Trials Group
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Respiratory and Cardiac Failure, Ministry of Health, Kuwait
- Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, And Intensive Care Department, King Abdulaziz Medical City, Ministry of National-Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Anesthesia and Critical Care Unit, Lady Reading Hospital, Peshawar, Pakistan
- Department of Critical Care Medicine, University of Alberta, And the Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Critical Care Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College Hospital, London, UK
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Critical Care Medicine, Fortis Escorts Hospital, Jaipur, India
- School of Medicine and Medical Sciences, University College Dublin, Ireland
- Department of Anaesthesia and Intensive Care, St Vincent's Hospital, Dublin, Ireland
- University College London, Institute of Health Informatics, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network – BricNet, Brazil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - the Brazilian Research in Intensive Care Network
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Respiratory and Cardiac Failure, Ministry of Health, Kuwait
- Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, And Intensive Care Department, King Abdulaziz Medical City, Ministry of National-Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Anesthesia and Critical Care Unit, Lady Reading Hospital, Peshawar, Pakistan
- Department of Critical Care Medicine, University of Alberta, And the Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Critical Care Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College Hospital, London, UK
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Critical Care Medicine, Fortis Escorts Hospital, Jaipur, India
- School of Medicine and Medical Sciences, University College Dublin, Ireland
- Department of Anaesthesia and Intensive Care, St Vincent's Hospital, Dublin, Ireland
- University College London, Institute of Health Informatics, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network – BricNet, Brazil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - the Critical Care Asia and Africa Network
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Respiratory and Cardiac Failure, Ministry of Health, Kuwait
- Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, And Intensive Care Department, King Abdulaziz Medical City, Ministry of National-Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Anesthesia and Critical Care Unit, Lady Reading Hospital, Peshawar, Pakistan
- Department of Critical Care Medicine, University of Alberta, And the Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Critical Care Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College Hospital, London, UK
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Critical Care Medicine, Fortis Escorts Hospital, Jaipur, India
- School of Medicine and Medical Sciences, University College Dublin, Ireland
- Department of Anaesthesia and Intensive Care, St Vincent's Hospital, Dublin, Ireland
- University College London, Institute of Health Informatics, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network – BricNet, Brazil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - the Irish Critical Care-Clinical Trials Group
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Al-Amiri Hospital, Ministry of Health, Kuwait
- Kuwait Extracorporeal Life Support Program, Al-Amiri Center for Respiratory and Cardiac Failure, Ministry of Health, Kuwait
- Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, And Intensive Care Department, King Abdulaziz Medical City, Ministry of National-Guard Health Affairs, Riyadh, Saudi Arabia
- Department of Anesthesia and Critical Care Unit, Lady Reading Hospital, Peshawar, Pakistan
- Department of Critical Care Medicine, University of Alberta, And the Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- National Intensive Care Surveillance - MORU (NICS-MORU), Colombo, Sri Lanka
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Critical Care Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
- Department of Health Promotion and Human Behavior, Kyoto University School of Public Health, Kyoto, Japan
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- University College Hospital, London, UK
- The Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Critical Care Medicine, Fortis Escorts Hospital, Jaipur, India
- School of Medicine and Medical Sciences, University College Dublin, Ireland
- Department of Anaesthesia and Intensive Care, St Vincent's Hospital, Dublin, Ireland
- University College London, Institute of Health Informatics, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
- HCor Research Institute, São Paulo, Brazil
- Brazilian Research in Intensive Care Network – BricNet, Brazil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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7
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Salvagno M, Taccone FS, Bogossian EG. Tissue hyperoxia is not a risk factor for cerebral vasospasm following subarachnoid hemorrhage. J Neurol Sci 2023; 445:120535. [PMID: 36630804 DOI: 10.1016/j.jns.2022.120535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/22/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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8
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Siwicka-Gieroba D, Robba C, Gołacki J, Badenes R, Dabrowski W. Cerebral Oxygen Delivery and Consumption in Brain-Injured Patients. J Pers Med 2022; 12:1763. [PMID: 36573716 PMCID: PMC9698645 DOI: 10.3390/jpm12111763] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/30/2022] Open
Abstract
Organism survival depends on oxygen delivery and utilization to maintain the balance of energy and toxic oxidants production. This regulation is crucial to the brain, especially after acute injuries. Secondary insults after brain damage may include impaired cerebral metabolism, ischemia, intracranial hypertension and oxygen concentration disturbances such as hypoxia or hyperoxia. Recent data highlight the important role of clinical protocols in improving oxygen delivery and resulting in lower mortality in brain-injured patients. Clinical protocols guide the rules for oxygen supplementation based on physiological processes such as elevation of oxygen supply (by mean arterial pressure (MAP) and intracranial pressure (ICP) modulation, cerebral vasoreactivity, oxygen capacity) and reduction of oxygen demand (by pharmacological sedation and coma or hypothermia). The aim of this review is to discuss oxygen metabolism in the brain under different conditions.
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Affiliation(s)
- Dorota Siwicka-Gieroba
- Department of Anaesthesiology and Intensive Care, Medical University in Lublin, 20-954 Lublin, Poland
| | - Chiara Robba
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 16132 Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, 16132 Genoa, Italy
| | - Jakub Gołacki
- Department of Anaesthesiology and Intensive Care, Medical University in Lublin, 20-954 Lublin, Poland
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari, University of Valencia, 46010 Valencia, Spain
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University in Lublin, 20-954 Lublin, Poland
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9
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Young PJ, Mackle D, Hodgson C, Bellomo R, Bailey M, Beasley R, Deane AM, Eastwood G, Finfer S, Freebairn R, King V, Linke N, Litton E, McArthur C, McGuinness S, Panwar R. Conservative or liberal oxygen therapy for mechanically ventilated adults with acute brain pathologies: A post-hoc subgroup analysis. J Crit Care 2022; 71:154079. [PMID: 35660843 DOI: 10.1016/j.jcrc.2022.154079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 04/10/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the effect of conservative vs. liberal oxygen therapy in mechanically ventilated adults in the intensive care unit (ICU) with non-hypoxic ischemic encephalopathy (HIE) acute brain pathologies. MATERIALS AND METHODS Post-hoc analysis of data from 217 patients with non-HIE acute brain pathologies included in the ICU Randomized Trial Comparing Two Approaches to OXygen therapy (ICU-ROX). RESULTS Patients allocated to conservative oxygen spent less time with oxygen saturation ≥ 97% (50.5 [interquartile range (IQR), 18.5-119] vs. 82 h [IQR, 38-164], absolute difference, -31.5 h; 95%CI, -59.6 to -3.4). At 180 days, 38 of 110 conservative oxygen patients (34.5%) and 28 of 104 liberal oxygen patients (26.9%) had died (absolute difference, 7.6 percentage points; 95%CI, -4.7 to 19.9 percentage points; P = 0.23; interaction P = 0.02 for non-HIE acute brain pathologies vs. HIE; interaction P = 0.53 for non-HIE acute brain pathologies vs. non-neurological conditions). CONCLUSIONS In this post-hoc analysis, patients admitted to the ICU with non-HIE acute brain pathologies treated with conservative oxygen therapy did not have significantly lower mortality than those treated with liberal oxygen. A trial with adequate statistical power is needed to determine whether our day 180 mortality point estimate of treatment effect favoring liberal oxygen therapy indicates a true effect.
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Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand; Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia.
| | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia; Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Adam M Deane
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Simon Finfer
- Critical Care Division and Trauma, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; School of Public Health, Imperial College London, London, England, UK
| | - Ross Freebairn
- Intensive Care Unit, Hawkes Bay Hospital, Hastings, New Zealand
| | - Victoria King
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Natalie Linke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand; Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Shay McGuinness
- Medical Research Institute of New Zealand, Wellington, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
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10
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The Impact of Short-Term Hyperoxia on Cerebral Metabolism: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:547-557. [PMID: 35641804 DOI: 10.1007/s12028-022-01529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis. METHODS We searched Medline and Scopus, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement; we searched for retrospective and prospective observational studies, interventional studies, and randomized clinical trials that performed a hyperoxia challenge in patients with acute brain injury who were concomitantly monitored with cerebral microdialysis. This study was registered in PROSPERO (CRD420211295223). RESULTS We included a total of 17 studies, with a total of 311 patients. A statistically significant reduction in cerebral lactate values (pooled standardized mean difference [SMD] - 0.38 [- 0.53 to - 0.23]) and lactate to pyruvate ratio values (pooled SMD - 0.20 [- 0.35 to - 0.05]) was observed after hyperoxia. However, glucose levels (pooled SMD - 0.08 [- 0.23 to 0.08]) remained unchanged after hyperoxia. CONCLUSIONS Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.
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11
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Svedung Wettervik T, Engquist H, Hånell A, Howells T, Rostami E, Ronne-Engström E, Lewén A, Enblad P. Cerebral Blood Flow and Oxygen Delivery in Aneurysmal Subarachnoid Hemorrhage: Relation to Neurointensive Care Targets. Neurocrit Care 2022; 37:281-292. [PMID: 35449343 PMCID: PMC9283361 DOI: 10.1007/s12028-022-01496-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/22/2022] [Indexed: 02/04/2023]
Abstract
Background The primary aim was to determine to what extent continuously monitored neurointensive care unit (neuro-ICU) targets predict cerebral blood flow (CBF) and delivery of oxygen (CDO2) after aneurysmal subarachnoid hemorrhage. The secondary aim was to determine whether CBF and CDO2 were associated with clinical outcome. Methods In this observational study, patients with aneurysmal subarachnoid hemorrhage treated at the neuro-ICU in Uppsala, Sweden, from 2012 to 2020 with at least one xenon-enhanced computed tomography (Xe-CT) obtained within the first 14 days post ictus were included. CBF was measured with the Xe-CT and CDO2 was calculated based on CBF and arterial oxygen content. Regional cerebral hypoperfusion was defined as CBF < 20 mL/100 g/min, and poor CDO2 was defined as CDO2 < 3.8 mL O2/100 g/min. Neuro-ICU variables including intracranial pressure (ICP), pressure reactivity index, cerebral perfusion pressure (CPP), optimal CPP, and body temperature were assessed in association with the Xe-CT. The acute phase was divided into early phase (day 1–3) and vasospasm phase (day 4–14). Results Of 148 patients, 27 had underwent a Xe-CT only in the early phase, 74 only in the vasospasm phase, and 47 patients in both phases. The patients exhibited cerebral hypoperfusion and poor CDO2 for medians of 15% and 30%, respectively, of the cortical brain areas in each patient. In multiple regressions, higher body temperature was associated with higher CBF and CDO2 in the early phase. In a similar regression for the vasospasm phase, younger age and longer pulse transit time (lower peripheral resistance) correlated with higher CBF and CDO2, whereas lower hematocrit only correlated with higher CBF but not with CDO2. ICP, CPP, and pressure reactivity index exhibited no independent association with CBF and CDO2. R2 of these regressions were below 0.3. Lower CBF and CDO2 in the early phase correlated with poor outcome, but this only held true for CDO2 in multiple regressions. Conclusions Systemic and cerebral physiological variables exhibited a modest association with CBF and CDO2. Still, cerebral hypoperfusion and low CDO2 were common and low CDO2 was associated with poor outcome. Xe-CT imaging could be useful to help detect secondary brain injury not evident by high ICP and low CPP. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01496-1.
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Affiliation(s)
| | - Henrik Engquist
- Department of Surgical Sciences/Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Anders Hånell
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
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12
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Francoeur CL, Lauzier F, Brassard P, Turgeon AF. Near Infrared Spectroscopy for Poor Grade Aneurysmal Subarachnoid Hemorrhage-A Concise Review. Front Neurol 2022; 13:874393. [PMID: 35518206 PMCID: PMC9062216 DOI: 10.3389/fneur.2022.874393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Delayed cerebral ischemia (DCI) disproportionately affects poor grade aneurysmal subarachnoid hemorrhage (aSAH) patients. An unreliable neurological exam and the lack of appropriate monitoring leads to unrecognized DCI, which in turn is associated with severe long-term deficits and higher mortality. Near Infrared Spectroscopy (NIRS) offers simple, continuous, real time, non-invasive cerebral monitoring. It provides regional cerebral oxygen saturation (c-rSO2), which reflects the balance between cerebral oxygen consumption and supply. Reports have demonstrated a good correlation with other cerebral oxygen and blood flow monitoring, and credible cerebrovascular reactivity indices were also derived from NIRS signals. Multiple critical c-rSO2 values have been reported in aSAH patients, based on various thresholds, duration, variation from baseline or cerebrovascular reactivity indices. Some were associated with vasospasm, some with DCI and others with clinical outcomes. However, the poor grade aSAH population has not been specifically studied and no randomized clinical trial has been published. The available literature does not support a specific NIRS-based intervention threshold to guide diagnostic or treatment in aSAH patients. We review herein the fundamental basic concepts behind NIRS technology, relationship of c-rSO2 to other brain monitoring values and their potential clinical interpretation. We follow with a critical evaluation of the use of NIRS in the aSAH population, more specifically its ability to diagnose vasospasm, to predict DCI and its association to outcome. In summary, NIRS might offer significant potential for poor grade aSAH in the future. However, current evidence does not support its use in clinical decision-making, and proper technology evaluation is required.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, QC, Canada
- Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada
| | - Alexis F. Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), Centre Hospitalier Universitaire (CHU) de Québec—Université Laval Research Centre, Université Laval, Québec City, QC, Canada
- Department of Anesthesiology and Critical Care, CHU de Québec—Université Laval, Critical Care Division, Québec City, QC, Canada
- Critical Care Medicine Service, CHU de Québec—Université Laval, Québec City, QC, Canada
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13
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Ahn J, Mastorakos P, Sokolowski JD, Chen CJ, Kellogg R, Park MS. Effects of hyperoxemia on aneurysmal subarachnoid hemorrhage outcomes: a systematic review and meta-analysis. Neurosurg Focus 2022; 52:E7. [PMID: 35231897 DOI: 10.3171/2021.12.focus21660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/10/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE In recent years, hyperoxemia in the intensive care unit has received attention as potentially contributing to negative outcomes in the setting of cardiac arrest, ischemic stroke, and traumatic brain injury. The authors sought to evaluate whether hyperoxemia contributes to worse outcomes in the setting of aneurysmal subarachnoid hemorrhage (aSAH) and to summarize suggested pathophysiological mechanisms. METHODS A systematic literature review was conducted without date restrictions on the PubMed and Web of Science databases on September 15, 2021. All studies that assessed the relationship between patients treated for aSAH and hyperoxemia were eligible independent of the criteria used to define hyperoxemia. All nonclinical studies and studies that did not report outcome data specific to patients with aSAH were excluded. A total of 102 records were found and screened, resulting in assessment of 10 full-text studies, of which 7 met eligibility criteria. Risk of bias was assessed using the Downs and Black checklist. A meta-analysis on the pooled 2602 patients was performed, and forest plots were constructed. Additionally, a review of the literature was performed to summarize available data regarding the pathophysiology of hyperoxemia. RESULTS The included studies demonstrated an association between hyperoxemia and increased morbidity and mortality following aSAH. The criteria used to determine hyperoxemia varied among studies. Pooling of univariate data showed hyperoxemia to be associated with poor neurological outcome (OR 2.26, 95% CI 1.66-3.07; p < 0.001), delayed cerebral ischemia (DCI) (OR 1.91, 95% CI 1.31-2.78; p < 0.001), and increased incidence of poor neurological outcome or mortality as a combined endpoint (OR 2.36, 95% CI 1.87-2.97; p < 0.001). Pooling of multivariable effect sizes showed the same relationship for poor neurological outcome (OR 1.28, 95% CI 1.07-1.55; p = 0.01) and poor neurological outcome and mortality as a combined endpoint (OR 1.17, 95% CI 1.11-1.23; p < 0.001). Additionally, review of preclinical studies underlined the contribution of oxidative stress due to hyperoxemia to acute secondary brain injury and DCI. CONCLUSIONS Reported outcomes from the available studies have indicated that hyperoxemia is associated with worse neurological outcome, mortality, and DCI. These findings provide a general guideline toward avoiding hyperoxemia in the acute setting of aSAH. Further studies are needed to determine the optimal ventilation and oxygenation parameters for acute management of this patient population.
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Affiliation(s)
- Jungeun Ahn
- 1School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Panagiotis Mastorakos
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jennifer D Sokolowski
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ching-Jen Chen
- 3Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan Kellogg
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Min S Park
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
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14
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Svedung Wettervik T, Hånell A, Howells T, Ronne-Engström E, Enblad P, Lewén A. Association of Arterial Metabolic Content with Cerebral Blood Flow Regulation and Cerebral Energy Metabolism-A Multimodality Analysis in Aneurysmal Subarachnoid Hemorrhage. J Intensive Care Med 2022; 37:1442-1450. [PMID: 35171061 PMCID: PMC9548938 DOI: 10.1177/08850666221080054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background In this study, the association of the arterial content of oxygen, carbon
dioxide, glucose, and lactate with cerebral pressure reactivity, energy
metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage
(aSAH) was investigated. Methods In this retrospective study, 60 patients with aSAH, treated at the
neurointensive care (NIC), Uppsala University Hospital, Sweden, between 2016
and 2021 with arterial blood gas (ABG), intracranial pressure, and cerebral
microdialysis (MD) monitoring were included. The first 10 days were divided
into an early phase (day 1 to 3) and a vasospasm phase (day 4 to 10). Results Higher arterial lactate was independently associated with higher/worse
pressure reactivity index (PRx) in the early phase (β = 0.32,
P = .02), whereas higher pO2 had the
opposite association in the vasospasm phase (β = −0.30,
P = .04). Arterial glucose and pCO2 were not
associated with PRx. Higher arterial lactate (β = 0.29,
P = .05) was independently associated with higher
MD-glucose in the vasospasm phase, whereas higher pO2 had the
opposite association in the vasospasm phase (β = −0.33,
P = .03). Arterial glucose and pCO2 were not
associated with MD-glucose. Higher pCO2 in the early phase, lower
arterial glucose in both phases, and lower arterial lactate in the vasospasm
phase were associated (P < .05) with better clinical
outcome. Conclusions Arterial variables associated with more vasoconstriction (higher
pO2 and lower arterial lactate) were associated with better
cerebral pressure reactivity, but worse energy metabolism. In severe aSAH,
when cerebral large-vessel vasospasm with exhausted distal vasodilation is
common, more vasoconstriction could increase distal vasodilatory reserve and
pressure reactivity, but also reduce cerebral blood flow and metabolic
supply. The MD may be useful to monitor the net effects on cerebral
metabolism in PRx-targeted NIC.
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15
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Singer M, Young PJ, Laffey JG, Asfar P, Taccone FS, Skrifvars MB, Meyhoff CS, Radermacher P. Dangers of hyperoxia. Crit Care 2021; 25:440. [PMID: 34924022 PMCID: PMC8686263 DOI: 10.1186/s13054-021-03815-y] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/04/2021] [Indexed: 01/27/2023] Open
Abstract
Oxygen (O2) toxicity remains a concern, particularly to the lung. This is mainly related to excessive production of reactive oxygen species (ROS). Supplemental O2, i.e. inspiratory O2 concentrations (FIO2) > 0.21 may cause hyperoxaemia (i.e. arterial (a) PO2 > 100 mmHg) and, subsequently, hyperoxia (increased tissue O2 concentration), thereby enhancing ROS formation. Here, we review the pathophysiology of O2 toxicity and the potential harms of supplemental O2 in various ICU conditions. The current evidence base suggests that PaO2 > 300 mmHg (40 kPa) should be avoided, but it remains uncertain whether there is an "optimal level" which may vary for given clinical conditions. Since even moderately supra-physiological PaO2 may be associated with deleterious side effects, it seems advisable at present to titrate O2 to maintain PaO2 within the normal range, avoiding both hypoxaemia and excess hyperoxaemia.
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Affiliation(s)
- Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London, UK
| | - Paul J Young
- Medical Research Institute of New Zealand, and Intensive Care Unit, Wellington Hospital, Wellington, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Department of Critical Care Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, and School of Medicine, National University of Ireland, Galway, Ireland
| | - Pierre Asfar
- Département de Médecine Intensive - Réanimation Et Médecine Hyperbare, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
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16
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Busani S, Sarti M, Serra F, Gelmini R, Venturelli S, Munari E, Girardis M. Revisited Hyperoxia Pathophysiology in the Perioperative Setting: A Narrative Review. Front Med (Lausanne) 2021; 8:689450. [PMID: 34746165 PMCID: PMC8569225 DOI: 10.3389/fmed.2021.689450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/22/2021] [Indexed: 01/05/2023] Open
Abstract
The widespread use of high-dose oxygen, to avoid perioperative hypoxemia along with WHO-recommended intraoperative hyperoxia to reduce surgical site infections, is an established clinical practice. However, growing pathophysiological evidence has demonstrated that hyperoxia exerts deleterious effects on many organs, mainly mediated by reactive oxygen species. The purpose of this narrative review was to present the pathophysiology of perioperative hyperoxia on surgical wound healing, on systemic macro and microcirculation, on the lungs, heart, brain, kidneys, gut, coagulation, and infections. We reported here that a high systemic oxygen supply could induce oxidative stress with inflammation, vasoconstriction, impaired microcirculation, activation of hemostasis, acute and chronic lung injury, coronary blood flow disturbances, cerebral ischemia, surgical anastomosis impairment, gut dysbiosis, and altered antibiotics susceptibility. Clinical studies have provided rather conflicting results on the definitions and outcomes of hyperoxic patients, often not speculating on the biological basis of their results, while this review highlighted what happens when supranormal PaO2 values are reached in the surgical setting. Based on the assumptions analyzed in this study, we may suggest that the maintenance of PaO2 within physiological ranges, avoiding unnecessary oxygen administration, may be the basis for good clinical practice.
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Affiliation(s)
- Stefano Busani
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Marco Sarti
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Francesco Serra
- Chirurgia Generale d'Urgenza e Oncologica, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Roberta Gelmini
- Chirurgia Generale d'Urgenza e Oncologica, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Sophie Venturelli
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Elena Munari
- Chirurgia Generale d'Urgenza e Oncologica, Azienda Universitaria Policlinico di Modena, Modena, Italy
| | - Massimo Girardis
- Cattedra e Servizio di Anestesia e Rianimazione, Azienda Universitaria Policlinico di Modena, Modena, Italy
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17
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Frase S, Steimer M, Selzner L, Kaiser S, Foit NA, Niesen WD, Schallner N. Temporal Expression Pattern of Hemoxygenase-1 Expression and Its Association with Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:279-291. [PMID: 34312792 PMCID: PMC8813853 DOI: 10.1007/s12028-021-01299-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 06/11/2021] [Indexed: 12/01/2022]
Abstract
Background Red blood cell-induced cerebral inflammation and toxicity has been shown to be attenuated by induction of the heme-catalyzing enzyme, hemoxygenase-1 (HO-1), in animal models of subarachnoid hemorrhage (SAH). Although inflammatory mechanisms leading to secondary neuronal injury in SAH are becoming increasingly well understood, markers of cerebral inflammation have so far not been implemented in clinical prediction models of SAH. Methods In this biomarker observational study, HO-1 messenger ribonucleic acid (mRNA) expression levels were determined in cerebrospinal fluid (CSF) and blood of 66 patients with aneurysmal SAH on days 1, 7, and 14 after the SAH event. HO-1 mRNA expression was determined via real time polymerase chain reaction (PCR), and relative expression changes were quantified in comparison with expression levels in nonhemorrhagic control CSF. Subarachnoid blood burden, as well as presence of vasospasm and delayed cerebral ischemia (DCI), were recorded. Short and long-term clinical outcomes were assessed using the Modified Rankin Scale at discharge and 1 year after the SAH event. Results CSF HO-1 expression levels showed a significant increase over the 14-day observation period (p < 0.001, F = 22.53) and correlated with intracranial hematoma burden (ρ = 0.349, p = 0.025). In multivariate analyses, CSF HO-1 expression levels did not reach significance as independent predictors of outcome. Vasospasm on computed tomographic angiography was associated with lower CSF HO-1 expression levels on day 7 after SAH (n = 53, p = 0.010), whereas patients with DCI showed higher CSF HO-1 expression levels on day 14 after SAH (n = 21, p = 0.009). Conclusions HO-1 expression in CSF in patients with SAH follows a distinct temporal induction pattern and is dependent on intracranial hematoma burden. CSF HO-1 expression was unable to predict functional outcome. Associations of early low HO-1 expression with vasospasm and late elevated HO-1 expression with DCI may point to detrimental effects of late HO-1 induction, warranting the need for further investigation in a larger study population.
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Affiliation(s)
- Sibylle Frase
- Department of Neurology and Neuroscience, Medical Center - University of Freiburg, Freiburg, Germany.
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Matti Steimer
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Lisa Selzner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Sandra Kaiser
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
| | - Niels Alexander Foit
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neuroscience, Medical Center - University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Schallner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Freiburg, Germany
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18
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Lucke-Wold B, Hosaka K, Dodd W, Motwani K, Laurent D, Martinez M, Hoh B. Interleukin-6: Important Mediator of Vasospasm Following Subarachnoid Hemorrhage. Curr Neurovasc Res 2021; 18:364-369. [PMID: 34736380 PMCID: PMC10127255 DOI: 10.2174/1567202618666211104122408] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 02/08/2023]
Abstract
The correlation of neuroinflammation with the development of cerebral vasospasm following subarachnoid hemorrhage has been well documented in the literature; both clinical and preclinical. The exact mechanisms by which this process occurs, however, are poorly elucidated. Recent evidence indicates that interleukin-6 is not only an important prognostic biomarker for subarachnoid hemorrhage and subsequent vasospasm development but also an integral component in the progression of injury following initial insult. In this review, we briefly highlight other pathways under investigation and focus heavily on what has been discovered regarding the role of interleukin 6 and cerebral vasospasm following subarachnoid hemorrhage. A proposed mechanistic pathway is highlighted in written and graphical format. A discussion regarding the human correlative findings and initial pre-clinical mechanistic studies is addressed. Finally, in the future investigation section, innovative developments and a clear description of areas warranting further scientific inquiry are emphasized. This review will catalyze continued discovery in this area of emerging significance and aid in the quest for effective vasospasm treatment where limited clinical therapeutics currently exist.
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Affiliation(s)
- Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Koji Hosaka
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - William Dodd
- College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Kartik Motwani
- College of Medicine, University of Florida, Gainesville, FL 32608, USA
| | - Dimitri Laurent
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Melanie Martinez
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Brian Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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