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Lee HY, Mamadjonov N, Jung YH, Jeung KW, Kim TH, Kim JW, Kim HJ, Gumucio JA, Salcido DD. Relationships of Jugular Bulb Parameters with Cerebral Perfusion and Metabolism After Resuscitation from Cardiac Arrest: A Post-Hoc Analysis of Experimental Studies Using a Minipig Model. Neurocrit Care 2024:10.1007/s12028-024-02084-1. [PMID: 39117965 DOI: 10.1007/s12028-024-02084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Cerebral blood flow (CBF) decreases in the first few hours or days following resuscitation from cardiac arrest, increasing the risk of secondary cerebral injury. Using data from experimental studies performed in minipigs, we investigated the relationships of parameters derived from arterial and jugular bulb blood gas analyses and lactate levels (jugular bulb parameters), which have been used as indicators of cerebral perfusion and metabolism, with CBF and the cerebral lactate to creatine ratio measured with dynamic susceptibility contrast magnetic resonance imaging and proton magnetic resonance spectroscopy, respectively. METHODS We retrospectively analyzed 36 sets of the following data obtained during the initial hours following resuscitation from cardiac arrest: percent of measured CBF relative to that at the prearrest baseline (%CBF), cerebral lactate to creatine ratio, and jugular bulb parameters, including jugular bulb oxygen saturation, jugular bulb lactate, arterial-jugular bulb oxygen content difference, cerebral extraction of oxygen, jugular bulb-arterial lactate content difference, lactate oxygen index, estimated respiratory quotient, and arterial-jugular bulb hydrogen ion content difference. Linear mixed-effects models were constructed to examine the effects of each jugular bulb parameter on the %CBF and cerebral lactate to creatine ratio. RESULTS The arterial-jugular bulb oxygen content difference (P = 0.047) and cerebral extraction of oxygen (P = 0.030) had a significant linear relationship with %CBF, but they explained only 12.0% (95% confidence interval [CI] 0.002-0.371) and 14.2% (95% CI 0.005-0.396) of the total %CBF variance, respectively. The arterial-jugular bulb hydrogen ion content difference had a significant linear relationship with cerebral lactate to creatine ratio (P = 0.037) but explained only 13.8% (95% CI 0.003-0.412) of the total variance in the cerebral lactate to creatine ratio. None of the other jugular bulb parameters were related to the %CBF or cerebral lactate to creatine ratio. CONCLUSIONS In conclusion, none of the jugular bulb parameters appeared to provide sufficient information on cerebral perfusion and metabolism in this setting.
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Affiliation(s)
- Hyoung Youn Lee
- Trauma Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical Science, Chonnam National University Graduate School, Gwangju, Republic of Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Medical School, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Medical School, 42 Jebong-ro, Donggu, Gwangju, 61469, Republic of Korea.
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Tae-Hoon Kim
- Medical Convergence Research Center, Wonkwang University, Iksan, Republic of Korea
| | - Jin Woong Kim
- Department of Radiology, Chosun University Hospital, Gwangju, Republic of Korea
- Department of Radiology, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Hyung Joong Kim
- Medical Science Research Institute, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Jorge Antonio Gumucio
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David D Salcido
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Shao R, Wang T, Hang C, An L, Wang X, Zhang L, Yu J, Shan Z, Yang Q, Tang Z. Alteration in early resting‑state functional MRI activity in comatose survivors of cardiac arrest: a prospective cohort study. Crit Care 2024; 28:260. [PMID: 39095884 PMCID: PMC11295486 DOI: 10.1186/s13054-024-05045-4] [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] [Received: 05/09/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND This study aimed to explore the characteristics of abnormal regional resting-state functional magnetic resonance imaging (rs-fMRI) activity in comatose patients in the early period after cardiac arrest (CA), and to investigate their relationships with neurological outcomes. We also explored the correlations between jugular venous oxygen saturation (SjvO2) and rs-fMRI activity in resuscitated comatose patients. We also examined the relationship between the amplitude of the N20-baseline and the rs-fMRI activity within the intracranial conduction pathway of somatosensory evoked potentials (SSEPs). METHODS Between January 2021 and January 2024, eligible post-resuscitated patients were screened to undergo fMRI examination. The amplitude of low-frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity (ReHo) of rs-fMRI blood oxygenation level-dependent (BOLD) signals were used to characterize regional neural activity. Neurological outcomes were evaluated using the Glasgow-Pittsburgh cerebral performance category (CPC) scale at 3 months after CA. RESULTS In total, 20 healthy controls and 31 post-resuscitated patients were enrolled in this study. The rs-fMRI activity of resuscitated patients revealed complex changes, characterized by increased activity in some local brain regions and reduced activity in others compared to healthy controls (P < 0.05). However, the mean ALFF values of the whole brain were significantly greater in CA patients (P = 0.011). Among the clusters of abnormal rs-fMRI activity, the cluster values of ALFF in the left middle temporal gyrus and inferior temporal gyrus and the cluster values of ReHo in the right precentral gyrus, superior frontal gyrus and middle frontal gyrus were strongly correlated with the CPC score (P < 0.001). There was a strong correlation between the mean ALFF and SjvO2 in CA patients (r = 0.910, P < 0.001). The SSEP N20-baseline amplitudes in CA patients were negatively correlated with thalamic rs-fMRI activity (all P < 0.001). CONCLUSIONS This study revealed that abnormal rs-fMRI BOLD signals in resuscitated patients showed complex changes, characterized by increased activity in some local brain regions and reduced activity in others. Abnormal BOLD signals were associated with neurological outcomes in resuscitated patients. The mean ALFF values of the whole brain were closely related to SjvO2 levels, and changes in the thalamic BOLD signals correlated with the N20-baseline amplitudes of SSEP responses. TRIAL REGISTRATION NCT05966389 (Registered July 27, 2023).
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Affiliation(s)
- Rui Shao
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Tao Wang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Chenchen Hang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Le An
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Xingsheng Wang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Luying Zhang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Jingfei Yu
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Zhenyu Shan
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China
| | - Qi Yang
- Department of Radiology, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
| | - Ziren Tang
- Department of Emergency Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8# Worker's Stadium South Road, Chao-yang District, Beijing, 100020, China.
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Perkins GD, Neumar R, Hsu CH, Hirsch KG, Aneman A, Becker LB, Couper K, Callaway CW, Hoedemaekers CWE, Lim SL, Meurer W, Olasveengen T, Sekhon MS, Skrifvars M, Soar J, Tsai MS, Vengamma B, Nolan JP. Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation. Resuscitation 2024; 201:110196. [PMID: 38932555 DOI: 10.1016/j.resuscitation.2024.110196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.
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Slovis JC, Bach A, Beaulieu F, Zuckerberg G, Topjian A, Kirschen MP. Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification. Neurocrit Care 2024; 40:99-115. [PMID: 37002474 PMCID: PMC10544744 DOI: 10.1007/s12028-023-01685-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. METHODS In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. RESULTS For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. CONCLUSION Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA.
| | - Ashley Bach
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Gabe Zuckerberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
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Lee HY, Jung YH, Mamadjonov N, Jeung KW, Lee BK, Kim T, Kim HJ, Gumucio JA, Salcido DD. Assessment of the Effects of Sodium Nitroprusside Administered Via Intracranial Subdural Catheters on the Cerebral Blood Flow and Lactate Using Dynamic Susceptibility Contrast Magnetic Resonance Imaging and Proton Magnetic Resonance Spectroscopy in a Pig Cardiac Arrest Model. J Am Heart Assoc 2023; 12:e029774. [PMID: 37776216 PMCID: PMC10727238 DOI: 10.1161/jaha.123.029774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/29/2023] [Indexed: 10/02/2023]
Abstract
Background Cerebral blood flow (CBF) is impaired in the early phase after return of spontaneous circulation. Sodium nitroprusside (SNP) administration via intracranial subdural catheters improves cerebral cortical microcirculation. We determined whether the SNP treatment improves CBF in the subcortical tissue and evaluated the effects of this treatment on cerebral lactate. Methods and Results Sixty minutes after return of spontaneous circulation following 14 minutes of untreated cardiac arrest, 14 minipigs randomly received 4 mg SNP or saline via intracranial subdural catheters. CBF was measured in regions of interest within the cerebrum and thalamus using dynamic susceptibility contrast-magnetic resonance imaging. After return of spontaneous circulation, CBF was expressed as a percentage of the baseline value. In the saline group, the %CBF in the regions of interest within the cerebrum remained at approximately 50% until 3.5 hours after return of spontaneous circulation, whereas %CBF in the thalamic regions of interest recovered to approximately 73% at this time point. The percentages of the baseline values in the cortical gray matter and subcortical white matter were higher in the SNP group (group effect P=0.026 and 0.025, respectively) but not in the thalamus. The cerebral lactate/creatine ratio measured using magnetic resonance spectroscopy increased over time in the saline group but not in the SNP group (group-time interaction P=0.035). The thalamic lactate/creatine ratio was similar in the 2 groups. Conclusions SNP administered via intracranial subdural catheters improved CBF not only in the cortical gray matter but also in the subcortical white matter. The CBF improvement by SNP was accompanied by a decrease in cerebral lactate.
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Affiliation(s)
- Hyoung Youn Lee
- Trauma CenterChonnam National University HospitalGwangjuRepublic of Korea
| | - Yong Hun Jung
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Najmiddin Mamadjonov
- Department of Medical ScienceChonnam National University Graduate SchoolGwangjuRepublic of Korea
| | - Kyung Woon Jeung
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Byung Kook Lee
- Department of Emergency MedicineChonnam National University HospitalGwangjuRepublic of Korea
- Department of Emergency MedicineChonnam National University Medical SchoolGwangjuRepublic of Korea
| | - Tae‐Hoon Kim
- Medical Convergence Research CenterWonkwang UniversityIksanRepublic of Korea
| | - Hyung Joong Kim
- Medical Science Research InstituteKyung Hee University HospitalSeoulRepublic of Korea
| | - Jorge Antonio Gumucio
- Department of Emergency MedicineSchool of Medicine University of PittsburghPittsburghPAUSA
| | - David D. Salcido
- Department of Emergency MedicineSchool of Medicine University of PittsburghPittsburghPAUSA
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Srinivasan V, Hall J, Wahlster S, Johnson NJ, Branch K. Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest. Resuscitation 2023; 190:109858. [PMID: 37270091 DOI: 10.1016/j.resuscitation.2023.109858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND/OBJECTIVE Post-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. METHODS This is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. RESULTS A total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01-1.11, p < 0.01). CONCLUSION Signs of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.
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Affiliation(s)
- Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, United States.
| | - Jane Hall
- Department of Emergency Medicine, University of Washington School of Medicine, United States
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, United States; Department of Neurosurgery, University of Washington School of Medicine, United States; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington School of Medicine, United States; Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, United States
| | - Kelley Branch
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, United States
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Hoiland RL, Robba C, Menon DK, Citerio G, Sandroni C, Sekhon MS. Clinical targeting of the cerebral oxygen cascade to improve brain oxygenation in patients with hypoxic-ischaemic brain injury after cardiac arrest. Intensive Care Med 2023; 49:1062-1078. [PMID: 37507572 PMCID: PMC10499700 DOI: 10.1007/s00134-023-07165-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023]
Abstract
The cerebral oxygen cascade includes three key stages: (a) convective oxygen delivery representing the bulk flow of oxygen to the cerebral vascular bed; (b) diffusion of oxygen from the blood into brain tissue; and (c) cellular utilisation of oxygen for aerobic metabolism. All three stages may become dysfunctional after resuscitation from cardiac arrest and contribute to hypoxic-ischaemic brain injury (HIBI). Improving convective cerebral oxygen delivery by optimising cerebral blood flow has been widely investigated as a strategy to mitigate HIBI. However, clinical trials aimed at optimising convective oxygen delivery have yielded neutral results. Advances in the understanding of HIBI pathophysiology suggest that impairments in the stages of the oxygen cascade pertaining to oxygen diffusion and cellular utilisation of oxygen should also be considered in identifying therapeutic strategies for the clinical management of HIBI patients. Culprit mechanisms for these impairments may include a widening of the diffusion barrier due to peri-vascular oedema and mitochondrial dysfunction. An integrated approach encompassing both intra-parenchymal and non-invasive neuromonitoring techniques may aid in detecting pathophysiologic changes in the oxygen cascade and enable patient-specific management aimed at reducing the severity of HIBI.
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Affiliation(s)
- Ryan L Hoiland
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada.
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - David K Menon
- Department of Medicine, University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
- Collaborative Entity for REsearching Brain Ischemia (CEREBRI), University of British Columbia, Vancouver, BC, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Schoenthal T, Hoiland R, Griesdale DE, Sekhon MS. Cerebral hemodynamics after cardiac arrest: implications for clinical management. Minerva Anestesiol 2023; 89:824-833. [PMID: 37676177 DOI: 10.23736/s0375-9393.23.17268-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Following resuscitation from cardiac arrest, hypoxic ischemic brain injury (HIBI) ensues, which is the primary determinant of adverse outcome. The pathophysiology of HIBI can be compartmentalized into primary and secondary injury, resulting from cerebral ischemia during cardiac arrest and reperfusion following successful resuscitation, respectively. During the secondary injury phase, increased attention has been directed towards the optimization of cerebral oxygen delivery to prevent additive injury to the brain. During this phase, cerebral hemodynamics are characterized by early hyperemia following resuscitation and then a protracted phase of cerebral hypoperfusion termed "no-reflow" during which additional hypoxic-ischemic injury can occur. As such, identification of therapeutic strategies to optimize cerebral delivery of oxygen is at the forefront of HIBI research. Unfortunately, randomized control trials investigating the manipulation of arterial carbon dioxide tension and mean arterial pressure augmentation as methods to potentially improve cerebral oxygen delivery have shown no impact on clinical outcomes. Emerging literature suggests differential patient-specific phenotypes may exist in patients with HIBI. The potential to personalize therapeutic strategies in the critical care setting based upon patient-specific pathophysiology presents an attractive strategy to improve HIBI outcomes. Herein, we review the cerebral hemodynamic pathophysiology of HIBI, discuss patient phenotypes as it pertains to personalizing care, as well as suggest future directions.
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Affiliation(s)
- Tison Schoenthal
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Hoiland
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Center for Heart, Lung, and Vascular Health, School of Health and Exercise Sciences, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
| | - Donald E Griesdale
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
- Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada -
- International Collaboration on Repair Discoveries, Vancouver, BC, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, BC, Canada
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Abstract
PURPOSE OF REVIEW To describe the available neuromonitoring tools in patients who are comatose after resuscitation from cardiac arrest because of hypoxic-ischemic brain injury (HIBI). RECENT FINDINGS Electroencephalogram (EEG) is useful for detecting seizures and guiding antiepileptic treatment. Moreover, specific EEG patterns accurately identify patients with irreversible HIBI. Cerebral blood flow (CBF) decreases in HIBI, and a greater decrease with no CBF recovery indicates poor outcome. The CBF autoregulation curve is narrowed and right-shifted in some HIBI patients, most of whom have poor outcome. Parameters derived from near-infrared spectroscopy (NIRS), intracranial pressure (ICP) and transcranial Doppler (TCD), together with brain tissue oxygenation, are under investigation as tools to optimize CBF in patients with HIBI and altered autoregulation. Blood levels of brain biomarkers and their trend over time are used to assess the severity of HIBI in both the research and clinical setting, and to predict the outcome of postcardiac arrest coma. Neuron-specific enolase (NSE) is recommended as a prognostic tool for HIBI in the current postresuscitation guidelines, but other potentially more accurate biomarkers, such as neurofilament light chain (NfL) are under investigation. SUMMARY Neuromonitoring provides essential information to detect complications, individualize treatment and predict prognosis in patients with HIBI.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario ‘Agostino Gemelli’- IRCCS
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Markus Benedikt Skrifvars
- Department of Emergency Medicine and Services, University of Helsinki
- Helsinki University Hospital, Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Liou FY, Tsai MS, Kuo LK, Hsu HH, Lai CH, Lin KC, Huang WC. A Study on the Outcome of Targeted Temperature Management Comparing Cardiac Arrest Patients Who Received Bystander Cardiopulmonary Resuscitation With Those Who Did Not, Using the Nationwide TIMECARD Multicenter Registry. Front Med (Lausanne) 2022; 9:779781. [PMID: 35492359 PMCID: PMC9043113 DOI: 10.3389/fmed.2022.779781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Targeted temperature management (TTM) is associated with decreased mortality and improved neurological function after cardiac arrest. Additionally, studies have shown that bystander cardiopulmonary resuscitation (BCPR) doubled the survival of patients with out-of-hospital cardiac arrest (OHCA) compared to patients who received no BPCR (no-BCPR). However, the outcome benefits of BCPR on patients who received TTM are not fully understood. Therefore, this study aimed to investigate the outcome differences between BCPR and no-BCPR in patients who received TTM after cardiac arrest. Methods The Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) multicenter registry established a study cohort and a database for patients receiving TTM between January 2013 and September 2019. A total of 580 patients were enrolled and divided into 376 and 204 patients in the BCPR and no-BCPR groups, respectively. Results Compared to the no-BCPR group, the BCPR group had a better hospital discharge and survival rate (42.25 vs. 31.86%, P = 0.0305). The BCPR group also had a better neurological outcome at hospital discharge. It had a higher average GCS score (11.3 vs. 8.31, P < 0.0001) and a lower average Glasgow-Pittsburgh cerebral performance category (CPC) scale score (2.14 vs. 2.98, P < 0.0001). After undertaking a multiple logistic regression analysis, it was found that BCPR was a significant positive predictor for in-hospital survival (OR = 0.66, 95% CI: 0.45-0.97, P = 0.0363). Conclusions This study demonstrated that BCPR had a positive survival and neurological impact on the return of spontaneous circulation (ROSC) in patients receiving TTM after cardiac arrest.
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Affiliation(s)
- Fang-Yu Liou
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Education Center, National Cheng Kung University, Tainan, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Hsin-Hui Hsu
- Department of Critical Care Medicine, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Clinical Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
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11
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Individualized cerebral perfusion pressure in acute neurological injury: are we ready for clinical use? Curr Opin Crit Care 2022; 28:123-129. [PMID: 35058408 DOI: 10.1097/mcc.0000000000000919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Individualizing cerebral perfusion pressure based on cerebrovascular autoregulation assessment is a promising concept for neurological injuries where autoregulation is typically impaired. The purpose of this review is to describe the status quo of autoregulation-guided protocols and discuss steps towards clinical use. RECENT FINDINGS Retrospective studies have indicated an association of impaired autoregulation and poor clinical outcome in traumatic brain injury (TBI), hypoxic-ischemic brain injury (HIBI) and aneurysmal subarachnoid hemorrhage (aSAH). The feasibility and safety to target a cerebral perfusion pressure optimal for cerebral autoregulation (CPPopt) after TBI was recently assessed by the COGITATE trial. Similarly, the feasibility to calculate a MAP target (MAPopt) based on near-infrared spectroscopy was demonstrated for HIBI. Failure to meet CPPopt is associated with the occurrence of delayed cerebral ischemia in aSAH but interventional trials in this population are lacking. No level I evidence is available on potential effects of autoregulation-guided protocols on clinical outcomes. SUMMARY The effect of autoregulation-guided management on patient outcomes must still be demonstrated in prospective, randomized, controlled trials. Selection of disease-specific protocols and endpoints may serve to evaluate the overall benefit from such approaches.
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12
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Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med 2021; 47:1393-1414. [PMID: 34705079 PMCID: PMC8548866 DOI: 10.1007/s00134-021-06548-2] [Citation(s) in RCA: 172] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its treatment options, its outcomes, and the suggested strategies for outcome prediction.
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Affiliation(s)
- Claudio Sandroni
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy. .,Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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13
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Richter J, Sklienka P, Chatterjee N, Maca J, Zahorec R, Burda M. Elevated jugular venous oxygen saturation after cardiac arrest. Resuscitation 2021; 169:214-219. [PMID: 34678332 DOI: 10.1016/j.resuscitation.2021.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We performed a retrospective analysis of our earlier study on cerebral oxygenation monitoring by jugular venous oximetry (SjvO2) in patients of out-of-hospital cardiac arrest (OHCA). The study was focused on high SjvO2 values (≥75%) and their association with neurological outcomes and serum neuron-specific enolase (NSE) concentration. METHOD Forty OHCA patients were divided into (i) high (Group I), (ii) normal (Group II), and (iii) low (Group III) SjvO2, with the mean SjvO2 ≥ 75%, 55-74% and <55% respectively. The neurological outcome was evaluated using the Cerebral Performance Category scale (CPC) on the 90th day after cardiac arrest (post-CA). NSE concentration was determined after ICU admission and then at 24, 48, and 72 hours (h) post-CA. RESULTS High mean SjvO2 occurred in 67% of patients, while no patients had low mean SjvO2. The unfavourable outcome was significantly more common in Group I than Group II (74% versus 23%, p < 0.01). Group I patients had significantly higher median NSE than Group II at 48 and 72 h post-CA. A positive correlation was found between SjvO2 and PaCO2. Each 1 kPa increase in CO2 led to an increase of SjvO2 by 2.2 %+/-0.66 (p < 0.01) in group I and by 5.7%+/-1.36 (p < 0.0001) in group II. There was no correlation between SjvO2 and MAP or SjvO2 and PaO2. CONCLUSION High mean SjvO2 are often associated with unfavourable outcomes and high NSE at 48 and 72 hours post-CA. Not only low but also high SjvO2 values may require therapeutic intervention.
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Affiliation(s)
- Jaromir Richter
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Peter Sklienka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Nilay Chatterjee
- Department of Anaesthetics, Yeovil Hospital, Yeovil, United Kingdom
| | - Jan Maca
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic; Department of Intensive Care Medicine and Forensic Studies, Institute of Physiology and Pathophysiology Faculty Of Medicine, University of Ostrava, Czech Republic
| | - Roman Zahorec
- Second Department of Anesthesiology and Intensive Medicine, Medical School, Comenius University, Bratislava, Slovak Republic
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, University of Ostrava, Czech Republic
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14
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Grand J, Hassager C, Bro-Jeppesen J, Gustafsson F, Møller JE, Boesgaard S, Nielsen N, Kjaergaard J. Impact of Hypothermia on Oxygenation Variables and Metabolism in Survivors of Out-of-Hospital Cardiac Arrest Undergoing Targeted Temperature Management at 33°C Versus 36°C. Ther Hypothermia Temp Manag 2020; 11:170-178. [PMID: 32584698 DOI: 10.1089/ther.2020.0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Targeted temperature management (TTM) exerts substantial impact on hemodynamic function in out-of-hospital cardiac arrest (OHCA) patients. Whole-body oxygen consumption (VO2) and delivery (DO2) have not previously been investigated in a clinical setting during TTM at different levels of temperature after OHCA. A substudy of 151 patients randomized at a single center in the TTM-trial, where patients were randomly assigned TTM at 33°C (TTM33) or 36°C (TTM36) for 24 hours. We calculated VO2 according to the principle of Fick (VO2 = cardiac output*arteriovenous oxygen content difference). DO2 was calculated as cardiac output*arterial oxygen content. Cardiac output was measured by pulmonary artery catheter with thermodilution. Arteriovenous oxygen content difference was calculated from arterial and mixed venous oxygen saturation and hemoglobin. Oxygen extraction ratio = VO2/DO2. At 24 hours, the VO2 was 169 ± 59 mL O2 per minute in TTM33 and 217 ± 53 mL O2 per minute in TTM36 (p < 0.0001). During 24 hours of TTM, the overall difference was 53 mL O2 minute (95% confidence interval [CI]: 31-74, pgroup < 0.0001). After rewarming at 36 and 48 hours, there was no difference in VO2 between the groups. DO2 was overall 277 mL O2 per minute (95% CI: 175-379, pgroup < 0.0001) higher in the TTM36-group during TTM. Oxygen extraction ratio during TTM was not significantly different between the two groups (2% [95% CI: -0.1 to 5, pgroup = 0.09]). VO2 during the first 36 hours after OHCA correlated significantly with temperature, and VO2 was 19 mL O2 per minute lower per degree reduction in temperature (95% CI: 15-22), p < 0.0001. TTM at 33°C compared to 36°C after OHCA is associated with significantly lower VO2 and DO2, however, oxygen extraction ratio was not significantly different. For each degree lower body temperature, the VO2 fell by 19 mL O2 per minute.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - John Bro-Jeppesen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Søren Boesgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Niklas Nielsen
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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15
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Francoeur CL, Lee J, Dangayach N, Gidwani U, Mayer SA. Non-invasive cerebral perfusion monitoring in cardiac arrest patients: a prospective cohort study. Clin Neurol Neurosurg 2020; 196:105970. [PMID: 32505869 DOI: 10.1016/j.clineuro.2020.105970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To determine if non-invasive cerebral perfusion estimation provided by a new acousto-optic technology can be used as a reliable predictor of neurological outcome. PATIENTS AND METHODS We performed a prospective, observational cohort study of consecutive comatose patients successfully resuscitated from out-of-hospital cardiac arrest. Patients were monitored using c-FLOW (Ornim Medical) from critical care unit admission up to 72 h, full awakening, or death. Primary outcome was favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2. RESULTS A total of 21 patients were enrolled, without any loss to follow-up. Mean perfusion index over the monitoring period was not associated with functional outcome at hospital discharge (OR 1.03 [0.93, 1.17]). Adjustment for initial rhythm, time to return of spontaneous circulation and Glasgow coma scale motor score did not significantly alter the results (OR 1.06 [0.99, 1.12]). Mean perfusion index showed a poor discriminative value with an area under the curve of 0.60 for functional outcome (0.64 for survival). Correlation between the probes was weak (Pearson coefficient 0.35). CONCLUSION Cerebral perfusion monitoring using a c-FLOW device in survivors of cardiac arrest is feasible, but reliability of the information provided has yet to be demonstrated. In our cohort, we were unable to identify any association between the perfusion index and clinical outcomes at discharge. As such, clinical management of cardiac arrest patients based on non-invasive perfusion index is not supported and should be limited to research protocols. The trial was registered with ClinicalTrials.gov, number NCT02575196.
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Affiliation(s)
- Charles L Francoeur
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practises Research Unit (Trauma-Emergency-Critical Care Medicine), Université Laval, 1401, 18e rue, Québec City, Québec, Canada; Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada.
| | - James Lee
- Division of Neurocritical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, United States
| | - Neha Dangayach
- Departments of Neurology and Neurosurgery, Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, United States
| | - Umesh Gidwani
- Cardiology, Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, United States; Cardiac Critical Care Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, United States; Cardiac ICU & Cardiac Stepdown Unit, Mount Sinai Hospital, 1468 Madison Ave, New York, NY 10029, United States
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, 2799 W. Grand Blvd, Clara Ford Pavillion, Room 462, Detroit, MI 48202, United States; Neurology, Wayne State University School of Medicine, Detroit, Michigan, United States
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16
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Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients? J Clin Monit Comput 2020; 35:741-748. [PMID: 32435933 PMCID: PMC8286927 DOI: 10.1007/s10877-020-00530-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 05/13/2020] [Indexed: 01/31/2023]
Abstract
Cerebral protection against secondary hypoxic-ischemic brain injury is a key priority area in post-resuscitation intensive care management in survivors of cardiac arrest. Nevertheless, the current understanding of the incidence, diagnosis and its’ impact on neurological outcome remains undetermined. The aim of this study was to evaluate jugular bulb oximetry as a potential monitoring modality to detect the incidences of desaturation episodes during post-cardiac arrest intensive care management and to evaluate their subsequent impact on neurological outcome. We conducted a prospective, observational study in unconscious adult patients admitted to the intensive care unit who had successful resuscitation following out of hospital cardiac arrest of presumed cardiac causes. All the patients were treated as per European Resuscitation Council 2015 guidelines and they received jugular bulb catheter. Jugular bulb oximetry measurements were performed at six hourly intervals. The neurological outcomes were evaluated on 90th day after the cardiac arrest by cerebral performance categories scale. Forty patients met the eligibility criteria. Measurements of jugular venous oxygen saturation were performed for 438 times. Altogether, we found 2 incidences of jugular bulb oxygen saturation less than 50% (2/438; 0.46%), and 4 incidences when it was less than 55% (4/438; 0.91%). The study detected an association between SjVO2 and CO2 (r = 0.26), each 1 kPa increase in CO2 led to an increase in SjvO2 by 3.4% + / − 0.67 (p < 0.0001). There was no association between SjvO2 and PaO2 or SjvO2 and MAP. We observed a statistically significant higher mean SjvO2 (8.82% + / − 2.05, p < 0.0001) in unfavorable outcome group. The episodes of brain hypoxia detected by jugular bulb oxygen saturation were rare during post-resuscitation intensive care management in out of hospital cardiac arrest patients. Therefore, this modality of monitoring may not yield any additional information towards prevention of secondary hypoxic ischemic brain injury in post cardiac arrest survivors. Other factors contributing towards high jugular venous saturation needs to be considered.
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17
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Rafi S, Tadie JM, Gacouin A, Leurent G, Bedossa M, Le Tulzo Y, Maamar A. Doppler sonography of cerebral blood flow for early prognostication after out-of-hospital cardiac arrest: DOTAC study. Resuscitation 2019; 141:188-194. [DOI: 10.1016/j.resuscitation.2019.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/11/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
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18
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The Burden of Brain Hypoxia and Optimal Mean Arterial Pressure in Patients With Hypoxic Ischemic Brain Injury After Cardiac Arrest*. Crit Care Med 2019; 47:960-969. [DOI: 10.1097/ccm.0000000000003745] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Jang J, Oh SH, Nam Y, Lee K, Choi HS, Jung SL, Ahn KJ, Park KN, Kim BS. Prognostic value of phase information of 2D T2*-weighted gradient echo brain imaging in cardiac arrest survivors: A preliminary study. Resuscitation 2019; 140:142-149. [PMID: 31153942 DOI: 10.1016/j.resuscitation.2019.05.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/20/2019] [Accepted: 05/23/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Predicting neurological outcomes after cardiac arrest is important to guide therapeutic decisions. We assessed the prognostic value of phase information of 2D T2*-weighted gradient echo imaging (T2*WI) of the brain in CA survivors. METHODS This study included cardiac arrest survivors who had undergone MRI for prognostication. After application of homodyne filtering to T2*WI phase images, the contrast of three venous structures was assessed as normal (score 0) or abnormal (score 1): the superior sagittal sinus, the cortical veins, and the thalamostriate veins. The scores were summarized into a gradient-recalled echo (GRE) summary score. The prognostic performances of T2*WI, diffusion-weighted imaging (DWI), electroencephalography and serum biomarkers were evaluated using receiver operating characteristic (ROC) curves. RESULTS Of the 39 enrolled patients, 12 (31%) had good outcomes and 27 (69%) had poor outcomes. ROC curve analysis showed that T2*WI had good prognostic performance; the area under the curve (AUC) of the GRE summary score (0.980, 95% confidence interval CI 0.950-1.000) was comparable to those of conventional outcome predictors, including DWI patterns (0.949, 95% CI 0.889-1.000). The AUC increased when the summary GRE score was added to DWI patterns (0.991, 95% CI 0.973-1.000), although the difference was not statistically significant (P=0.117). Most subjects with isoelectric electroencephalography (5/6) showed abnormally high phase contrast in the cerebral veins. CONCLUSIONS Filtered phase images of T2*WI showed good prognostic value and can reveal various features of the cerebral metabolic consequences of cardiac arrest, such as decreased neuronal activity and brain death-like patterns.
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Affiliation(s)
- Jinhee Jang
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Yoonho Nam
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kijeong Lee
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Seok Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - So-Lyung Jung
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kook-Jin Ahn
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bum-Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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20
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Robba C, Goffi A, Geeraerts T, Cardim D, Via G, Czosnyka M, Park S, Sarwal A, Padayachy L, Rasulo F, Citerio G. Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review. Intensive Care Med 2019; 45:913-927. [PMID: 31025061 DOI: 10.1007/s00134-019-05610-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/26/2019] [Indexed: 12/20/2022]
Abstract
Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.
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Affiliation(s)
- Chiara Robba
- Department of Anaesthesia and Intensive Care, Ospedale Policlinico San Martino IRCCS, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi, 15, 16100, Genoa, Italy.
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, University Hospital of Toulouse, Toulouse NeuroImaging Center (ToNIC), Inserm-UPS, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Soojin Park
- Division of Critical Care and Hospitalist Neurology, Department of Neurology, Columbia University, New York, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Llewellyn Padayachy
- Department of Neurosurgery, Faculty of Health Sciences, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Frank Rasulo
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
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21
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Ameloot K, De Deyne C, Eertmans W, Ferdinande B, Dupont M, Palmers PJ, Petit T, Nuyens P, Maeremans J, Vundelinckx J, Vanhaverbeke M, Belmans A, Peeters R, Demaerel P, Lemmens R, Dens J, Janssens S. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial. Eur Heart J 2019; 40:1804-1814. [DOI: 10.1093/eurheartj/ehz120] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/02/2018] [Accepted: 03/06/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Cathy De Deyne
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ward Eertmans
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Bert Ferdinande
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
| | - Pieter-Jan Palmers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
| | - Tibaut Petit
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Nuyens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Joren Maeremans
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Joris Vundelinckx
- Department of Anesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Ann Belmans
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Ronald Peeters
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Demaerel
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, and Leuven Brain Institute (LBI), KU Leuven, University of Leuven, Leuven, Belgium
| | - Jo Dens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, Genk, Belgium
- Faculty of Medicine and Life Sciences, University Hasselt, Diepenbeek, Belgium
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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22
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Ben-Hamouda N, Oddo M. Monitorage cérébral après arrêt cardiaque : techniques et utilité clinique potentielle. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’arrêt cardiaque cause une hypoxie-ischémie globale, suivi de reperfusion, qui est susceptible d’engendrer des effets délétères sur la perfusion et l’oxygénation cérébrales, ainsi que le métabolisme cellulaire. Dans ce contexte, et en l’absence de thérapies spcéfiques de l’ischémie-reperfusion globale, le traitement est essentiellement de soutien, visant à optimiser la perfusion et l’oxygénation cérébrale, dans le but de prévenir ou atténuer les dégâts secondaires sur la fonction cérébrale. Dans ce contexte, le monitorage cérébral multimodal, notamment les techniques non-invasives, ont une utilité potentielle à la phase agiuë de l’arrêt cardiaque. Le but prinicpal de cette revue est de décrire les techniques actuellement dipsonibles, en nous focalisant surtout sur les outils noninvasifs (doppler transcranien, spectrospcope de proche infrarouge, électroencéphalographie, pupillométrie automatisée proche infrarouge), leur utilité clinique potentielle ainsi que leurs limitations, dans la prise en charge aiguë (optimisation de la perfusion et de l’oxygénation cérébrales) ainsi que pour la détermination du pronostic précoce après arrêt cardiaque.
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23
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Cerebral Perfusion and Cerebral Autoregulation after Cardiac Arrest. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4143636. [PMID: 29854752 PMCID: PMC5964572 DOI: 10.1155/2018/4143636] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/28/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022]
Abstract
Out of hospital cardiac arrest is the leading cause of death in industrialized countries. Recovery of hemodynamics does not necessarily lead to recovery of cerebral perfusion. The neurological injury induced by a circulatory arrest mainly determines the prognosis of patients after cardiac arrest and rates of survival with a favourable neurological outcome are low. This review focuses on the temporal course of cerebral perfusion and changes in cerebral autoregulation after out of hospital cardiac arrest. In the early phase after cardiac arrest, patients have a low cerebral blood flow that gradually restores towards normal values during the first 72 hours after cardiac arrest. Whether modification of the cerebral blood flow after return of spontaneous circulation impacts patient outcome remains to be determined.
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