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Zhang H, Ai Y, Zhang X, Deng F, Jiang S, Xie S, Peng M, Chen W, Hu J, Deng S, Zhang L. Visualization of Blood-Brain Barrier Disruption in Septic Mice with the New Method Based on in Vivo Imaging Technology. Neurocrit Care 2024:10.1007/s12028-024-02018-x. [PMID: 38982003 DOI: 10.1007/s12028-024-02018-x] [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: 01/02/2024] [Accepted: 05/16/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Dynamic monitoring of the blood-brain barrier (BBB) functional status in septic mice can help to explore the pathological mechanisms. Therefore, we proposed a new method for monitoring BBB permeability and applied it to the detection of sepsis models. METHODS The new method involves the construction of an optical cranial window and in vivo imaging. We performed dynamic monitoring of BBB permeability and cerebral blood flow (CBF) in cecal ligation puncture (CLP) and endotoxemia (lipopolysaccharide [LPS]) mice. RESULTS The sensitivity and accuracy of this method were higher than those of Evans blue evaluation. The increase of BBB permeability in the group of CLP mice was relatively mild and correlated with overall survival, and the damage was irreversible. Contrarily, BBB damage in the LPS group was more acute and severe, unrelated to overall survival, but recoverable. The CBF decreased significantly in both model mouse groups 24 h after modeling, but only the CBF proportion decrease in the LPS group was significantly correlated with an increase in BBB permeability. Within 24 h after both models were established, the decrease in blood flow in the digestive organs occurred earlier than in the brain and kidneys, and the decrease in small intestine blood flow in the LPS group progressed faster. CONCLUSIONS We have successfully demonstrated the feasibility of our novel method to detect BBB permeability in mice. Our results revealed a significant difference in the BBB permeability change trend between the CLP and LPS model mice when survival curves were consistent. Notably, the CLP-model mice demonstrated a closer resemblance to clinical patients. Our findings suggest that early-stage brain tissue hypoperfusion has a greater impact on BBB function damage in endotoxemia mice, which is related to the faster progression of blood flow redistribution.
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Affiliation(s)
- Haisong Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Xiaolei Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Fuxing Deng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shiwei Jiang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Shucai Xie
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Milin Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Wei Chen
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Jiyun Hu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Songyun Deng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China.
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Faisal H, Farhat S, Grewal NK, Masud FN. ICU Delirium in Cardiac Patients. Methodist Debakey Cardiovasc J 2023; 19:74-84. [PMID: 37547895 PMCID: PMC10402849 DOI: 10.14797/mdcvj.1246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/23/2023] [Indexed: 08/08/2023] Open
Abstract
Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.
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Affiliation(s)
- Hina Faisal
- Center for Critical Care, Houston Methodist Hospital, Weill Cornell Graduate School of Medical Sciences, Houston, Texas, US
| | - Souha Farhat
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Graduate School of Medical Sciences, Houston, Texas, US
| | - Navneet K. Grewal
- Memorial Hermann Southwest Hospital, UT Health Houston, McGovern Medical School, Houston, Texas, US
| | - Faisal N. Masud
- Center for Critical Care, Houston Methodist Hospital, Weill Cornell Graduate School of Medical Sciences, Houston, Texas, US
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3
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The Effects of Rso2 and PI Monitoring Images on the Treatment of Premature Infants Based on Deep Learning. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:5671713. [PMID: 35242208 PMCID: PMC8888060 DOI: 10.1155/2022/5671713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 11/17/2022]
Abstract
In recent years, due to the combined effects of individual behavior, psychological factors, environmental exposure, medical conditions, biological factors, etc., the incidence of preterm birth has gradually increased, so the incidence of various complications of preterm infants has also become higher and higher. This article is aimed at studying the therapeutic effects of preterm infants and proposing the application of rSO2 and PI image monitoring based on deep learning to the treatment of preterm infants. This article introduces deep learning, blood perfusion index, preterm infants, and other related content in detail and conducts experiments on the treatment of rSO2 and PI monitoring images based on deep learning in preterm infants. The experimental results show that the rSO2 and PI monitoring images based on deep learning can provide great help for the treatment of preterm infants and greatly improve the treatment efficiency of preterm infants by at least 15%.
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Vanderlinden JA, Holden RM, Scott SH, Boyd JG. Cerebral Perfusion in Hemodialysis Patients: A Feasibility Study. Can J Kidney Health Dis 2021; 8:20543581211010654. [PMID: 34017595 PMCID: PMC8114747 DOI: 10.1177/20543581211010654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/21/2021] [Indexed: 11/15/2022] Open
Abstract
Background Patients on hemodialysis (HD) are known to exhibit low values of regional cerebral oxygenation (rSO2) and impaired cognitive functioning. The etiology of both is currently unknown. Objective To determine the feasibility of serially monitoring rSO2 in patients initiating HD. In addition, we sought to investigate how rSO2 is related to hemodynamic and dialysis parameters. Design Prospective observational study. Setting Single-center tertiary academic teaching hospital in Ontario, Canada. Participants Six patients initiating HD were enrolled in the study. Methods Feasibility was defined as successful study enrollment (>1 patient/month), successful consent rate (>70%), high data capture rates (>90%), and assessment tolerability. Regional cerebral oxygenation monitoring was performed 1 time/wk for the first year of dialysis. A neuropsychological battery was performed 3 times during the study: before dialysis initiation, 3 months, and 1 year after dialysis initiation. The neuropsychological battery included a traditional screening tool: the Repeatable Battery for the Assessment of Neuropsychological Status, and a robot-based assessment: Kinarm. Results Our overall consent rate was 33%, and our enrollment rate was 0.4 patients/mo. In total 243 rSO2 sessions were recorded, with a data capture rate of 91.4% (222/243) across the 6 patients. Throughout the study, no adverse interactions were reported. Correlations between rSO2 with hemodynamic and dialysis parameters showed individual patient variability. However, at the individual level, all patients demonstrated positive correlations between mean arterial pressure and rSO2. Patients who had more than 3 liters of fluid showed significant negative correlations with rSO2. Less cognitive impairment was detected after initiating dialysis. Limitation This small cohort limits conclusions that can be made between rSO2 and hemodynamic and dialysis parameters. Conclusions Prospectively monitoring rSO2 in patients was unfeasible in a single dialysis unit, due to low consent and enrollment rates. However, rSO2 monitoring may provide unique insights into the effects of HD on cerebral oxygenation that should be further investigated. Trial Registration Due to the feasibility nature of this study, no trial registration was performed.
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Affiliation(s)
| | - Rachel Mary Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Stephen Harold Scott
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| | - John Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
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5
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Badenes R, Bogossian EG, Chisbert V, Robba C, Oddo M, Taccone FS, Matta BF. The role of non-invasive brain oximetry in adult critically ill patients without primary brain injury. Minerva Anestesiol 2021; 87:1226-1238. [PMID: 33938677 DOI: 10.23736/s0375-9393.21.15333-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A primary objective in intensive care and perioperative settings is to promote an adequate supply and delivery of oxygen to tissues and organs, particularly to the brain. Cerebral near infrared spectroscopy (NIRS) is a non-invasive, continuous monitoring technique, that can be used to assess cerebral oxygenation. Using NIRS to monitor cerebral oximetry is not new, and has been in widespread use in neonates and cardiac surgery for decades. In addition, it has become common to see NIRS being used in adult and pediatric cardiac surgery, acute neurological diseases, neurosurgical procedures, vascular surgery, severe trauma and other acute medical diseases. Furthermore, recent evidence suggests a role for NIRS in the perioperative settings; detecting and preventing episodes of cerebral desaturation aiming to reduce the development of post-operative delirium. NIRS is not without its limitations; these include the risk of extra-cranial contamination, spatial limitations and skin blood flow/volume changes, as well being a measure of localized blood oxygenation underneath the sensor. However, NIRS is a non-invasive technique and can, therefore, be used in those patients without indications or justification for invasive brain monitoring; non-neurosurgical procedures such as liver transplantation, major orthopedic surgery and critically illness where the brain is at risk. The aim of this manuscript was to discuss the physical principles of NIRS and to report the current evidence regarding its use in critically ill patients without primary non-anoxic brain injury.
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Affiliation(s)
- Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain - .,Department of Surgery, School of Medicine, University of Valencia, Valencia, Spain - .,INCLIVA Health Research Institute, Valencia, Spain -
| | - Elisa G Bogossian
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Vicente Chisbert
- INCLIVA Health Research Institute, Valencia, Spain.,Escuela de Doctorado, Universidad Católica de Valencia, Valencia, Spain
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCSS S. Martino Hospital, Genoa, Italy
| | - Mauro Oddo
- Department of Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Basil F Matta
- Trauma and NeuroCritical Care Unit, Cambridge University Hospital, Cambridge, UK
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6
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Wood MD, Boyd JG, Wood N, Frank J, Girard TD, Ross-White A, Chopra A, Foster D, Griesdale DEG. The Use of Near-Infrared Spectroscopy and/or Transcranial Doppler as Non-Invasive Markers of Cerebral Perfusion in Adult Sepsis Patients With Delirium: A Systematic Review. J Intensive Care Med 2021; 37:408-422. [PMID: 33685273 PMCID: PMC8772019 DOI: 10.1177/0885066621997090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Several studies have previously reported the presence of altered cerebral perfusion during sepsis. However, the role of non-invasive neuromonitoring, and the impact of altered cerebral perfusion, in sepsis patients with delirium remains unclear. Methods: We performed a systematic review of studies that used near-infrared spectroscopy (NIRS) and/or transcranial Doppler (TCD) to assess adults (≥18 years) with sepsis and delirium. From study inception to July 28, 2020, we searched the following databases: Ovid MedLine, Embase, Cochrane Library, and Web of Science. Results: Of 1546 articles identified, 10 met our inclusion criteria. Although NIRS-derived regional cerebral oxygenation was consistently lower, this difference was only statistically significant in one study. TCD-derived cerebral blood flow velocity was inconsistent across studies. Importantly, both impaired cerebral autoregulation during sepsis and increased cerebrovascular resistance were associated with delirium during sepsis. However, the heterogeneity in NIRS and TCD devices, duration of recording (from 10 seconds to 72 hours), and delirium assessment methods (e.g., electronic medical records, confusion assessment method for the intensive care unit), precluded meta-analysis. Conclusion: The available literature demonstrates that cerebral perfusion disturbances may be associated with delirium in sepsis. However, future investigations will require consistent definitions of delirium, delirium assessment training, harmonized NIRS and TCD assessments (e.g., consistent measurement site and length of recording), as well as the quantification of secondary and tertiary variables (i.e., Cox, Mxa, MAPOPT), in order to fully assess the relationship between cerebral perfusion and delirium in patients with sepsis.
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Affiliation(s)
- Michael D Wood
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gordon Boyd
- Department of Critical Care Medicine, 4257Queen's University, Kingston, Ontario, Canada
| | - Nicole Wood
- Department of Physics, 8430University of Waterloo, Waterloo, Ontario, Canada
| | - James Frank
- Department of Physics, 7497Brock University, St. Catharines, Ontario, Canada
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Akash Chopra
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denise Foster
- Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, Department of Medicine, 8166University of British Columbia, Vancouver, British Columbia, Canada.,Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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7
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[Sepsis-associated encephalopathy : A nationwide survey on diagnostic procedures and neuromonitoring in German intensive care units]. Anaesthesist 2020; 70:112-120. [PMID: 32970160 PMCID: PMC7851101 DOI: 10.1007/s00101-020-00853-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/09/2020] [Accepted: 08/23/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Sepsis-associated encephalopathy (SAE) is one of the most frequent causes of neurocognitive impairment in intensive care patients. It is associated with increased hospital mortality and poor long-term neurocognitive outcome. To date there are no evidence-based recommendations for the diagnostics and neuromonitoring of SAE. OBJECTIVE The aim of the study was to evaluate the current clinical practice of diagnostics and neuromonitoring of SAE on intensive care units (ICU) in Germany. MATERIAL AND METHODS Based on available literature focusing on SAE, a questionnaire consisting of 26 items was designed and forwarded to 438 members of the Scientific Working Group for Intensive Care Medicine (WAKI) and the Scientific Working Group for Neuroanesthesia (WAKNA) as an online survey. RESULTS The total participation rate in the survey was 12.6% (55/438). A standardized diagnostic procedure of SAE was reported by 21.8% (12/55) of the participants. The majority of participants preferred delirium screening tools (50/55; 90.9%) and the clinical examination (49/55; 89.1%) to detect SAE. Brain imaging (26/55; 47.3%), laboratory/biomarker determination (15/55; 27.3%), electrophysiological techniques (14/55; 25.5%) and cerebrospinal fluid examination (12/55; 21.8%) are less frequently performed. The follow-up examination of SAE is most frequently performed by a clinical examination (45/55; 81.8%). Neuromonitoring techniques, such as continuous electroencephalography (31/55; 56.4%), transcranial doppler sonography (31/55; 56.4%) and near-infrared spectroscopy (18/55, 32.7%) are not frequently used. We observed statistically significant differences between the theoretically attributed importance and clinical practice. The great majority of respondents (48/55; 87.3%) endorse the development of guidelines containing recommendations for diagnostics and neuromonitoring in SAE. DISCUSSION This explorative survey demonstrated a great heterogeneity in diagnostics and neuromonitoring of SAE in German ICUs. Uniform concepts have not yet been established but are desired by the majority of study participants. Innovative biomarkers of neuroaxonal injury in blood and cerebrospinal fluid as well as electrophysiological and brain imaging techniques could provide valuable prognostic information on the neurocognitive outcome of patients and would thus be a useful addition to the clinical assessment of ICU patients with SAE.
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Nitzan M, Nitzan I, Arieli Y. The Various Oximetric Techniques Used for the Evaluation of Blood Oxygenation. SENSORS 2020; 20:s20174844. [PMID: 32867184 PMCID: PMC7506757 DOI: 10.3390/s20174844] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 12/12/2022]
Abstract
Adequate oxygen delivery to a tissue depends on sufficient oxygen content in arterial blood and blood flow to the tissue. Oximetry is a technique for the assessment of blood oxygenation by measurements of light transmission through the blood, which is based on the different absorption spectra of oxygenated and deoxygenated hemoglobin. Oxygen saturation in arterial blood provides information on the adequacy of respiration and is routinely measured in clinical settings, utilizing pulse oximetry. Oxygen saturation, in venous blood (SvO2) and in the entire blood in a tissue (StO2), is related to the blood supply to the tissue, and several oximetric techniques have been developed for their assessment. SvO2 can be measured non-invasively in the fingers, making use of modified pulse oximetry, and in the retina, using the modified Beer–Lambert Law. StO2 is measured in peripheral muscle and cerebral tissue by means of various modes of near infrared spectroscopy (NIRS), utilizing the relative transparency of infrared light in muscle and cerebral tissue. The primary problem of oximetry is the discrimination between absorption by hemoglobin and scattering by tissue elements in the attenuation measurement, and the various techniques developed for isolating the absorption effect are presented in the current review, with their limitations.
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Affiliation(s)
- Meir Nitzan
- Department of Physics/Electro-Optics Engineering, Jerusalem College of Technology, 21 Havaad Haleumi St., Jerusalem 91160, Israel;
- Correspondence:
| | - Itamar Nitzan
- Monash Newborn, Monash Children’s Hospital, Melbourne 3168, Australia;
- Department of Neonatology, Shaare Zedek Medical Center, Shmuel Bait St 12, Jerusalem 9103102, Israel
| | - Yoel Arieli
- Department of Physics/Electro-Optics Engineering, Jerusalem College of Technology, 21 Havaad Haleumi St., Jerusalem 91160, Israel;
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Cavaillon J, Singer M, Skirecki T. Sepsis therapies: learning from 30 years of failure of translational research to propose new leads. EMBO Mol Med 2020; 12:e10128. [PMID: 32176432 PMCID: PMC7136965 DOI: 10.15252/emmm.201810128] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 12/13/2022] Open
Abstract
Sepsis has been identified by the World Health Organization (WHO) as a global health priority. There has been a tremendous effort to decipher underlying mechanisms responsible for organ failure and death, and to develop new treatments. Despite saving thousands of animals over the last three decades in multiple preclinical studies, no new effective drug has emerged that has clearly improved patient outcomes. In the present review, we analyze the reasons for this failure, focusing on the inclusion of inappropriate patients and the use of irrelevant animal models. We advocate against repeating the same mistakes and propose changes to the research paradigm. We discuss the long-term consequences of surviving sepsis and, finally, list some putative approaches-both old and new-that could help save lives and improve survivorship.
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Affiliation(s)
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care MedicineUniversity College LondonLondonUK
| | - Tomasz Skirecki
- Laboratory of Flow Cytometry and Department of Anesthesiology and Intensive Care MedicineCentre of Postgraduate Medical EducationWarsawPoland
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10
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Varis E, Pettilä V, Wilkman E. Near-Infrared Spectroscopy in Adult Circulatory Shock: A Systematic Review. J Intensive Care Med 2020; 35:943-962. [PMID: 32077780 DOI: 10.1177/0885066620907307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Circulatory shock affects every third patient in intensive care units and is associated with high mortality. Near-infrared spectroscopy (NIRS) could serve as a means for monitoring tissue perfusion in circulatory shock. PURPOSE To assess the evidence of NIRS monitoring in circulatory shock, we conducted a systematic review of the literature. METHODS The study protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO). We searched PubMed, Ovid MEDLINE, Scopus, and EBM Reviews databases. The reference lists of included articles, last volumes of key journals, and NIRS monitor manufacturers' webpages were searched manually. Two reviewers independently selected included studies. The quality of studies was assessed. The qualitative synthesis was guided by 3 questions: First, does NIRS monitoring improve patient-centered outcomes in adult circulatory shock patient? Second, do NIRS-derived parameters predict patient-centered outcomes, such as mortality and organ dysfunction, and third, does NIRS monitoring give additional information to guide treatment decisions? MAIN RESULTS Eighteen observational studies with 927 patients were included. Because of considerable clinical heterogeneity of the data, we were not able to perform a meta-analysis. Also, due to lack of randomized controlled trials, the first review question could not be answered. Based on the current review, baseline tissue oxygen saturation (StO2) however seems to predict mortality and identify patients with most severe forms of circulatory shock. CONCLUSIONS Near-infrared spectroscopy-derived StO2 can predict mortality in circulatory shock, but high-quality data on the impact of NIRS monitoring are lacking. Furthermore, the marked heterogeneity of the studies makes combining the results of individual studies difficult. Standardization of methodology and clinical randomized trials are needed before wider clinical use.
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Affiliation(s)
- Elina Varis
- Department of Anesthesiology, 89593Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, 89593Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erika Wilkman
- Department of Anesthesiology, 89593Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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11
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Wood MD, Khan J, Lee KFH, Maslove DM, Muscedere J, Hunt M, Scott SH, Day A, Jacobson JA, Ball I, Slessarev M, O'Regan N, English SW, McCredie V, Chasse M, Griesdale D, Boyd JG. Assessing the relationship between near-infrared spectroscopy-derived regional cerebral oxygenation and neurological dysfunction in critically ill adults: a prospective observational multicentre protocol, on behalf of the Canadian Critical Care Trials Group. BMJ Open 2019; 9:e029189. [PMID: 31243036 PMCID: PMC6597627 DOI: 10.1136/bmjopen-2019-029189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Survivors of critical illness frequently exhibit acute and chronic neurological complications. The underlying aetiology of this dysfunction remains unknown but may be associated with cerebral ischaemia. This study will use near-infrared spectroscopy to non-invasively quantify regional cerebral oxygenation (rSO2) to assess the association between poor rSO2 during the first 72 hours of critical illness with delirium severity, as well as long-term sensorimotor and cognitive impairment among intensive care unit (ICU) survivors. Further, the physiological determinants of rSO2 will be examined. METHODS AND ANALYSIS This multicentre prospective observational study will consider adult patients (≥18 years old) eligible for enrolment if within 24 hours of ICU admission, they require mechanical ventilation and/or vasopressor support. For 72 hours, rSO2 will be continuously recorded, while vital signs (eg, heart rate) and peripheral oxygenation saturation will be concurrently captured with data monitoring software. Arterial and central venous gases will be sampled every 12 hours for the 72 hours recording period and will include: pH, PaO2, PaCO2, and haemoglobin concentration. Participants will be screened daily for delirium with the confusion assessment method (CAM)-ICU, whereas the brief-CAM will be used on the ward. At 3 and 12 months post-ICU discharge, neurological function will be assessed with the Repeatable Battery for the Assessment of Neuropsychological Status and KINARM sensorimotor and cognitive robot-based behavioural tasks. ETHICS AND DISSEMINATION The study protocol has been approved in Ontario by a central research ethics board (Clinical Trials Ontario); non-Ontario sites will obtain local ethics approval. The study will be conducted under the guidance of the Canadian Critical Care Trials Group (CCCTG) and the results of this study will be presented at national meetings of the CCCTG for internal peer review. Results will also be presented at national/international scientific conferences. On completion, the study findings will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03141619.
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Affiliation(s)
- Michael D Wood
- Centre For Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Jasmine Khan
- Centre For Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Kevin F H Lee
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David M Maslove
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Muscedere
- Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Miranda Hunt
- Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Stephen H Scott
- Centre For Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Andrew Day
- Department of Community Health and Epidemiology and CERU, Queen's University, Kingston, Ontario, Canada
| | | | - Ian Ball
- Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Marat Slessarev
- Medicine, Division of Geriatric Medicine, Western University, London, Ontario, Canada
| | - Niamh O'Regan
- Medicine, Division of Geriatric Medicine, Western University, London, Ontario, Canada
| | - Shane W English
- Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Victoria McCredie
- Medicine; Critical Care, University of Toronto; Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Michaël Chasse
- Medicine (Critical Care), Centre Hospitalier de L'Universite de Montreal, Montréal, Quebec, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gordon Boyd
- Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
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12
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Jouan Y, Seegers V, Meziani F, Grelon F, Megarbane B, Anguel N, Mira JP, Dequin PF, Gergaud S, Weiss N, Legay F, Le Tulzo Y, Conrad M, Robert R, Gonzalez F, Guitton C, Tamion F, Tonnelier JM, Guezennec P, Van Der Linden T, Vieillard-Baron A, Radermacher P, Asfar P. Effects of mean arterial pressure on arousal in sedated ventilated patients with septic shock: a SEPSISPAM post hoc exploratory study. Ann Intensive Care 2019; 9:54. [PMID: 31073873 PMCID: PMC6509319 DOI: 10.1186/s13613-019-0528-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/30/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND It is unknown whether the recommended mean arterial pressure (MAP) target of 65 mmHg during initial resuscitation of septic shock is sufficient to maintain cerebral perfusion. Thus, we tested the hypothesis that a higher MAP target in patients with septic shock may improve level of arousal. METHODS We performed a post hoc exploratory analysis of the SEPSISPAM trial, which assessed the effect of a "high-target" level of MAP (80-85 mmHg) versus the recommended "low-target" MAP (65-70 mm Hg) on mortality in patients with septic shock. Among the 776 patients originally recruited in SEPSISPAM trial, we selected those who were mechanically ventilated and sedated and with available evaluation of arousal level assessed by the Richmond Agitation and Sedation Scale (RASS). RESULTS We restricted our analysis to the period in which patients were treated with vasoactive drugs. Cumulative sedative drugs were assessed daily. A total of 532 patients were included in this study: 253 (47.6%) in the low-target group and 279 (52.4%) in the high-target group. Daily cumulative sedative drugs were similar in both groups. Compared to the low-target group, minimal and maximal RASS were significantly higher in the high-target group at day 2, 4 and 5. Furthermore, in order to consider the fact that multiple measures were done for each patient and to consider the global effect of time on these measures, we used a mixed linear regression and multivariate models: we confirmed that maximal RASS values were significantly higher in the high-target group. CONCLUSION In patients with septic shock who were mechanically ventilated and sedated, resuscitation with MAP target between 80 and 85 mmHg was associated with higher arousal level as compared to a MAP target between 65 and 70 mmHg.
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Affiliation(s)
- Youenn Jouan
- CHU de Tours, Médecine Intensive Réanimation, 2 bis, Boulevard Tonnellé, 37044, Tours Cedex 09, France
| | - Valérie Seegers
- ICO Angers, 15, rue André Boquel, 49055, Angers Cedex 02, France
| | - Ferhat Meziani
- CHU de Strasbourg - Hôpital Civil, Service de Réanimation Médicale, 1, Place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
| | - Fabien Grelon
- CH du Mans, Service de Réanimation Médico-Chirurgicale and USC, 194, Avenue Rubillard, 72037, Le Mans, Cedex 09, France
| | - Bruno Megarbane
- Hôpital Lariboisière APHP, Réanimation Médicale et Toxicologique, 2 rue Ambroise Paré, 75010, Paris, France
| | - Nadia Anguel
- CHU de Bicêtre, Réanimation Médicale, 78 avenue du Général Leclerc, 94275, Le Kremlin Bicêtre Cedex, France
| | - Jean-Paul Mira
- GH Cochin Saint Vincent de Paul, Médecine Intensive Réanimation, 27 rue du Faubourg Saint Jacques, 75679, Paris Cedex 14, France
| | - Pierre-François Dequin
- CHU de Tours, Médecine Intensive Réanimation, 2 bis, Boulevard Tonnellé, 37044, Tours Cedex 09, France
| | - Soizic Gergaud
- CHU Angers, Réanimation Chirurgicale, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Nicolas Weiss
- CHU La Pitié-Salpétrière, Service de Neurologie et Réanimation, 47-83 Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - François Legay
- CH Y.Le Foll, Réanimation Médicale, 10 rue Marcel Proust, 22027, Saint Brieuc Cedex 1, France
| | - Yves Le Tulzo
- CHRU Hôpital de Pontchaillou, Service de Réanimation Médicale et Infectieuse, 2 rue Henri Le Guilloux 35033, Rennes, France
| | - Marie Conrad
- Hôpital Central, Réanimation Médicale, 29 Av du Maréchal de Lattre de Tassigny, 54035, Nancy Cedex, France
| | - René Robert
- CHU Poitiers Hôpital Jean Bernard, Réanimation Médicale, 2 route de la milétrie, 86021, Poitiers Cedex, France
| | - Frédéric Gonzalez
- CHU Avicenne Bobigny Réanimation Polyvalente, 125 rue de Stalingrad, 93009, Bobigny, France
| | - Christophe Guitton
- CH du Mans, Service de Réanimation Médico-Chirurgicale and USC, 194, Avenue Rubillard, 72037, Le Mans, Cedex 09, France
| | - Fabienne Tamion
- CHU Rouen- Hôpital Charles Nicolle, Réanimation Médicale, 1 rue de Germont, 76031, Rouen Cedex, France
| | - Jean-Marie Tonnelier
- CHU La Cavale Blanche Réanimation Médicale Boulevard Tanguy Prigent, 29609, Brest, France
| | - Pierre Guezennec
- Hopital Mignon - CH Versailles, Réanimation Médicale, 177 rue de versailles, 78157, Le Chesnay, France
| | - Thierry Van Der Linden
- CHU Saint Philibert, Réanimation Médicale, 115 rue Grand But, BP 249, 59462, Lomme Cedex, France
| | - Antoine Vieillard-Baron
- Hôpital Ambroise Paré, Réanimation Médicale, 9 avenue Charles de Gaulle, 92104, Boulogne-Billancourt Cedex, France
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum, Ulm, Germany
| | - Pierre Asfar
- Médecine Intensive Réanimation, CHU d'Angers, 4 rue Larrey, 49933, Cedex 9, France.
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Wood MD, Jacobson JA, Maslove DM, Muscedere JG, Boyd JG. The physiological determinants of near-infrared spectroscopy-derived regional cerebral oxygenation in critically ill adults. Intensive Care Med Exp 2019; 7:23. [PMID: 31049754 PMCID: PMC6497723 DOI: 10.1186/s40635-019-0247-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/07/2019] [Indexed: 02/08/2023] Open
Abstract
Background To maintain adequate oxygen delivery to tissue, resuscitation of critically ill patients is guided by assessing surrogate markers of perfusion. As there is no direct indicator of cerebral perfusion used in routine critical care, identifying an accurate strategy to monitor brain perfusion is paramount. Near-infrared spectroscopy (NIRS) is a non-invasive technique to quantify regional cerebral oxygenation (rSO2) that has been used for decades during cardiac surgery which has led to targeted algorithms to optimize rSO2 being developed. However, these targeted algorithms do not exist during critical care, as the physiological determinants of rSO2 during critical illness remain poorly understood. Materials and methods This prospective observational study was an exploratory analysis of a nested cohort of patients within the CONFOCAL study (NCT02344043) who received high-fidelity vital sign monitoring. Adult patients (≥ 18 years) admitted < 24 h to a medical/surgical intensive care unit were eligible if they had shock and/or required mechanical ventilation. Patients underwent rSO2 monitoring with the FORESIGHT oximeter for 24 h, vital signs were concurrently recorded, and clinically ordered arterial blood gas samples and hemoglobin concentration were also documented. Simultaneous multiple linear regression was performed using all available predictors, followed by model selection using the corrected Akaike information criterion (AICc). Results Our simultaneous multivariate model included age, heart rate, arterial oxygen saturation, mean arterial pressure, pH, partial pressure of oxygen, partial pressure of carbon dioxide (PaCO2), and hemoglobin concentration. This model accounted for a significant proportion of variance in rSO2 (R2 = 0.58, p < 0.01) and was significantly associated with PaCO2 (p < 0.05) and hemoglobin concentration (p < 0.01). Our selected regression model using AICc accounted for a significant proportion of variance in rSO2 (R2 = 0.54, p < 0.01) and was significantly related to age (p < 0.05), PaCO2 (p < 0.01), hemoglobin (p < 0.01), and heart rate (p < 0.05). Conclusions Known and established physiological determinants of oxygen delivery accounted for a significant proportion of the rSO2 signal, which provides evidence that NIRS is a viable modality to assess cerebral oxygenation in critically ill adults. Further elucidation of the determinants of rSO2 has the potential to develop a NIRS-guided resuscitation algorithm during critical illness. Trial registration This trial is registered on clinicaltrials.gov (Identifier: NCT02344043), retrospectively registered January 8, 2015. Electronic supplementary material The online version of this article (10.1186/s40635-019-0247-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael D Wood
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada
| | - Jill A Jacobson
- Department of Psychology, Queen's University, 62 Arch Street, 318 Craine Hall, Kingston, ON, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada.,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada. .,Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada. .,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada.
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14
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Nitchingham A, Kumar V, Shenkin S, Ferguson KJ, Caplan GA. A systematic review of neuroimaging in delirium: predictors, correlates and consequences. Int J Geriatr Psychiatry 2018; 33:1458-1478. [PMID: 28574155 DOI: 10.1002/gps.4724] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Neuroimaging advances our understanding of delirium pathophysiology and its consequences. A previous systematic review identified 12 studies (total participants N = 764, delirium cases N = 194; years 1989-2007) and found associations with white matter hyperintensities (WMH) and cerebral atrophy. Our objectives were to perform an updated systematic review of neuroimaging studies in delirium published since January 2006 and summarise the available literature on predictors, correlates or outcomes. METHODS Studies were identified by keyword and MeSH-based electronic searches of EMBASE, MEDLINE and PsycINFO combining terms for neuroimaging, brain structure and delirium. We included neuroimaging studies of delirium in adults using validated delirium assessment methods. RESULTS Thirty-two studies (total N = 3187, delirium N = 1086) met the inclusion criteria. Imaging included magnetic resonance imaging (MRI; N = 9), computed tomography (N = 4), diffusion tensor imaging (N = 3), transcranial Doppler (N = 5), near infrared spectroscopy (N = 5), functional-MRI (N = 2), single photon emission computed tomography (N = 1), proton MRI spectroscopy (N = 1), arterial spin-labelling MRI (N = 1) and 2-13 fluoro-2-deoxyglucose positron emission tomography (N = 1). Despite heterogeneity in study design, delirium was associated with WMH, lower brain volume, atrophy, dysconnectivity, impaired cerebral autoregulation, reduced blood flow and cerebral oxygenation and glucose hypometabolism. There was evidence of long-term brain changes following intensive care unit delirium. CONCLUSIONS Neuroimaging is now used more widely in delirium research due to advances in technology. However, imaging delirious patients presents challenges leading to methodological limitations and restricted generalisability. The findings that atrophy and WMH burden predict delirium replicates findings from the original review, while advanced techniques have identified other substrates and mechanisms that warrant further investigation.
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Affiliation(s)
- Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Varun Kumar
- Department of Psychiatry, Blacktown Hospital, Sydney, Australia
| | - Susan Shenkin
- Department of Geriatric Medicine, The University of Edinburgh, Edinburgh, UK
| | - Karen J Ferguson
- Department of Geriatric Medicine, The University of Edinburgh, Edinburgh, UK
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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15
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Bendahan N, Neal O, Ross-White A, Muscedere J, Boyd JG. Relationship Between Near-Infrared Spectroscopy-Derived Cerebral Oxygenation and Delirium in Critically Ill Patients: A Systematic Review. J Intensive Care Med 2018; 34:514-520. [PMID: 30376764 DOI: 10.1177/0885066618807399] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A common neurological complication of critical illness is delirium, defined as an acute change in level of consciousness, with impaired attention and disorganized thinking. Patients with delirium have increased risk of long-term cognitive dysfunction and mortality. The cause is unknown, which limits our ability to design therapeutic interventions. In patients undergoing surgery, low regional cerebral oxygenation (rSO2), as measured by near-infrared spectroscopy (NIRS), is associated with postoperative neurological dysfunction (eg delirium and long-term cognitive impairment). However, the relationship between NIRS-derived rSO2 and neurological outcomes in critically ill patients is unclear. The objective of this study was to assess the utilization of NIRS-derived rSO2 in critically ill patients outside the operating theater. We aimed to examine the relationship between rSO2 and neurological outcomes as well as to report rSO2 values in this population. METHODS The following databases were searched from inception to August 14, 2017: Ovid MedLine, Embase, Cochrane Library, and Web of Science. RESULTS Of 1410 articles identified by the search strategy, 8 were ultimately selected for final review. Most (7 of 8) were published since 2014. These studies included a total of 213 patients primarily with shock or respiratory failure. A variety of devices were used to measure rSO2, including INVOS and FORESIGHT. The duration of recording varied from 5 minutes to 72 hours. Four of the 8 studies reported on neurological outcomes. In all 4 studies, rSO2 was lower in critically ill patients who were delirious compared to controls, but this was only statistically significant in 2 of the studies. The heterogeneity in devices and duration of recording precluded meta-analysis. CONCLUSIONS There is limited literature describing rSO2 in critically ill patients outside the operating room. Although there may be a slight signal of an association between low rSO2 and delirium, more study is needed to explore this relationship.
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Affiliation(s)
- Nathaniel Bendahan
- 1 Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Oliver Neal
- 2 Undergraduate Medical Education Program, Queen's University, Kingston, Ontario, Canada
| | | | - John Muscedere
- 4 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - J Gordon Boyd
- 1 Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
- 4 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
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16
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Use of a Short-Acting β1 Blocker During Endotoxemia May Reduce Cerebral Tissue Oxygenation if Hemodynamics are Depressed by a Decrease in Heart Rate. Shock 2018; 47:765-771. [PMID: 28505021 DOI: 10.1097/shk.0000000000000795] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A decrease in heart rate (HR) using a short-acting β blocker has potential benefits in sepsis; however, depression of hemodynamics and reduction of cerebral oxygenation may also occur in endotoxemia. METHODS Seventeen swine were allocated to landiolol or control groups. In the landiolol group, the dose was sequentially changed from 0 to 40 to 200 μg kg min, and stopped. Hemodynamics, blood variables, and the cerebral tissue oxygenation index (TOI) were recorded by near infrared spectroscopy at each dose. Lipopolysaccharide (LPS) was then administered continuously at 1 μg kg h after a 100 μg bolus administration. After 30 and 150 min, as two severity stages of endotoxemia (endotoxemia 1 and 2), landiolol was administered as above and measurements were made. In the control group, landiolol was not administered, but measurements were made. RESULTS LPS increased HR and landiolol decreased HR, with similar effects in each endotoxemia stage. In endotoxemia 1, LPS decreased stroke volume (SV), but landiolol restored SV to a value similar to that before endotoxemia, and did not decrease cardiac output (CO), even at 200 μg kg min. In contrast, landiolol did not restore SV in endotoxemia 2, resulting in a decrease in CO and mean arterial pressure, accompanied with a dose-dependent decrease in TOI. CONCLUSIONS A short-acting β blocker has various hemodynamic effects in endotoxemia. Use of a short-acting β blocker during endotoxemia may reduce cerebral tissue oxygenation if hemodynamics are depressed by a decrease in HR.
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17
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Tannert A, Ramoji A, Neugebauer U, Popp J. Photonic monitoring of treatment during infection and sepsis: development of new detection strategies and potential clinical applications. Anal Bioanal Chem 2017; 410:773-790. [PMID: 29214536 DOI: 10.1007/s00216-017-0713-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/06/2017] [Accepted: 10/17/2017] [Indexed: 01/02/2023]
Abstract
Despite the strong decline in the infection-associated mortality since the development of the first antibiotics, infectious diseases are still a major cause of death in the world. With the rising number of antibiotic-resistant pathogens, the incidence of deaths caused by infections may increase strongly in the future. Survival rates in sepsis, which occurs when body response to infections becomes uncontrolled, are still very poor if an adequate therapy is not initiated immediately. Therefore, approaches to monitor the treatment efficacy are crucially needed to adapt therapeutic strategies according to the patient's response. An increasing number of photonic technologies are being considered for diagnostic purpose and monitoring of therapeutic response; however many of these strategies have not been introduced into clinical routine, yet. Here, we review photonic strategies to monitor response to treatment in patients with infectious disease, sepsis, and septic shock. We also include some selected approaches for the development of new drugs in animal models as well as new monitoring strategies which might be applicable to evaluate treatment response in humans in the future. Figure Label-free probing of blood properties using photonics.
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Affiliation(s)
- Astrid Tannert
- Leibniz Institute of Photonic Technology, Albert-Einstein-Str. 9, 07745, Jena, Germany
- Jena Biophotonics and Imaging Laboratory, 07745, Jena, Germany
| | - Anuradha Ramoji
- Leibniz Institute of Photonic Technology, Albert-Einstein-Str. 9, 07745, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Ute Neugebauer
- Leibniz Institute of Photonic Technology, Albert-Einstein-Str. 9, 07745, Jena, Germany.
- Jena Biophotonics and Imaging Laboratory, 07745, Jena, Germany.
- Center for Sepsis Control and Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
- Institute of Physical Chemistry, Friedrich Schiller University Jena, Helmholtzweg 4, 07743, Jena, Germany.
- InfectoGnostics Research Campus Jena, Philosophenweg 7, Jena, Germany.
| | - Jürgen Popp
- Leibniz Institute of Photonic Technology, Albert-Einstein-Str. 9, 07745, Jena, Germany
- Jena Biophotonics and Imaging Laboratory, 07745, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
- Institute of Physical Chemistry, Friedrich Schiller University Jena, Helmholtzweg 4, 07743, Jena, Germany
- InfectoGnostics Research Campus Jena, Philosophenweg 7, Jena, Germany
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18
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Maslove DM, Lamontagne F, Marshall JC, Heyland DK. A path to precision in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:79. [PMID: 28366166 PMCID: PMC5376689 DOI: 10.1186/s13054-017-1653-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Precision medicine is increasingly touted as a groundbreaking new paradigm in biomedicine. In the ICU, the complexity and ambiguity of critical illness syndromes have been identified as fundamental justifications for the adoption of a precision approach to research and practice. Inherently protean diseases states such as sepsis and acute respiratory distress syndrome have manifestations that are physiologically and anatomically diffuse, and that fluctuate over short periods of time. This leads to considerable heterogeneity among patients, and conditions in which a “one size fits all” approach to therapy can lead to widely divergent results. Current ICU therapy can thus be seen as imprecise, with the potential to realize substantial gains from the adoption of precision medicine approaches. A number of challenges still face the development and adoption of precision critical care, a transition that may occur incrementally rather than wholesale. This article describes a few concrete approaches to addressing these challenges. First, novel clinical trial designs, including registry randomized controlled trials and platform trials, suggest ways in which conventional trials can be adapted to better accommodate the physiologic heterogeneity of critical illness. Second, beyond the “omics” technologies already synonymous with precision medicine, the data-rich environment of the ICU can generate complex physiologic signatures that could fuel precision-minded research and practice. Third, the role of computing infrastructure and modern informatics methods will be central to the pursuit of precision medicine in the ICU, necessitating close collaboration with data scientists. As work toward precision critical care continues, small proof-of-concept studies may prove useful in highlighting the potential of this approach.
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Affiliation(s)
- David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada. .,Department of Medicine, Queen's University, Kingston, ON, Canada. .,Department of Critical Care Medicine, Kingston General Hospital, Davies 2, 76 Stuart St., Kingston, Ontario, K7L 2V7, Canada.
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
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19
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Can the cerebral regional oxygen saturation be a perfusion parameter in shock? J Crit Care 2016; 38:164-167. [PMID: 27915164 DOI: 10.1016/j.jcrc.2016.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Shock, defined as a state of tissue hypoperfusion and the tissues reperfusion, is the main goal of management of shock. Increase in central venous saturation (CvSo2) and decrease in blood lactate level are useful in assessment of adequacy of tissue perfusion. Near-infrared spectroscopy is a noninvasive way to observe real-time changes in regional cerebral saturation and has been used in patients with different brain diseases. There is a small body of literature suggesting that cerebral regional oxygen saturation (CrSo2) monitoring added a value in assessment and management of intensive care unit (ICU) patients. OBJECTIVES The aim of this study was to determine if CrSo2 can be used as an indicator of tissue perfusion in ICU patients with shock, and to determine the prognostic value of CrSo2 in survival prediction. METHODS This is a prospective single-center pilot study entailed 20 patients who were diagnosed with shock admitted to adult ICU at King Fahd Military Medical Complex, Dhahran, Saudi Arabia. The CrSo2 was monitored with near-infrared spectroscopy using Somatic, INVOS Oximeter 5100C (Covidien, Mansfield, Mass) with bilateral frontal electrode and mean value of the 2 readings was taken as well as blood lactate level, CvSo2, mean arterial blood pressure, and cardiac index at baseline time, 8, 24, 48, and 72 hours. All patients with history of cerebrovascular diseases and those who presented with neurological deficits were excluded from the study. RESULTS Significant negative correlation was noticed between CrSo2 and lactic acid at 8, 24, 48, and 72 hours from admission (r=-0.625, -0.711, -0.745, and -0.722, respectively; P=.003, .001, .001, and .001, respectively). Significant positive correlation was noticed between CrSo2 and CvSo2 at 8, 24, 48, and 72 hours from admission (r=0.572, 0.674, 0.527, and 0.757; P=.008, .001, .017, and .001, respectively). In addition, significant positive correlation was found between CrSo2 and mean arterial pressure at 24, 48, and 72 hours from admission (r=0.523, 0.513, and 0.626, respectively; P=.018, .021, and .003, respectively). Significant difference was also detected between the value of CrSo2 in the survivors (12 patients) and the nonsurvivors (8 patients) after 72 hours from admission, as it was 52.58%±7.33% and 44.75%±9.44% (P=.049), whereas it was not significantly different in the first 3 days. CONCLUSIONS Cerebral regional oxygen saturation might be helpful as one of the perfusion parameters in patients with shock and it could have a prognostic value in mortality prediction. However, further studies with larger sample size are still needed to validate these results.
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20
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Sims CR, Nguyen TC, Mayeux PR. Could Biomarkers Direct Therapy for the Septic Patient? J Pharmacol Exp Ther 2016; 357:228-39. [PMID: 26857961 DOI: 10.1124/jpet.115.230797] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/05/2016] [Indexed: 01/25/2023] Open
Abstract
Sepsis is a serious medical condition caused by a severe systemic inflammatory response to a bacterial, fungal, or viral infection that most commonly affects neonates and the elderly. Advances in understanding the pathophysiology of sepsis have resulted in guidelines for care that have helped reduce the risk of dying from sepsis for both children and older adults. Still, over the past three decades, a large number of clinical trials have been undertaken to evaluate pharmacological agents for sepsis. Unfortunately, all of these trials have failed, with the use of some agents even shown to be harmful. One key issue in these trials was the heterogeneity of the patient population that participated. What has emerged is the need to target therapeutic interventions to the specific patient's underlying pathophysiological processes, rather than looking for a universal therapy that would be effective in a "typical" septic patient, who does not exist. This review supports the concept that identification of the right biomarkers that can direct therapy and provide timely feedback on its effectiveness will enable critical care physicians to decrease mortality of patients with sepsis and improve the quality of life of survivors.
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Affiliation(s)
- Clark R Sims
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (C.R.S., P.R.M.); and Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas (T.C.N.)
| | - Trung C Nguyen
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (C.R.S., P.R.M.); and Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas (T.C.N.)
| | - Philip R Mayeux
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas (C.R.S., P.R.M.); and Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas (T.C.N.)
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