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Barea-Mendoza JA, Molina-Collado Z, Ballesteros-Sanz MÁ, Corral-Ansa L, Misis Del Campo M, Pardo-Rey C, Tihista-Jiménez JA, Corcobado-Márquez C, Martín Del Rincón JP, Llompart-Pou JA, Marcos-Prieto LA, Olazabal-Martínez A, Herrán-Monge R, Díaz-Lamas AM, Chico-Fernández M. Effects of PEEP on intracranial pressure in patients with acute brain injury: An observational, prospective and multicenter study. Med Intensiva 2024:S2173-5727(24)00132-2. [PMID: 38816286 DOI: 10.1016/j.medine.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/30/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To analyze the impact of positive end-expiratory pressure (PEEP) changes on intracranial pressure (ICP) dynamics in patients with acute brain injury (ABI). DESIGN Observational, prospective and multicenter study (PEEP-PIC study). SETTING Seventeen intensive care units in Spain. PATIENTS Neurocritically ill patients who underwent invasive neuromonitorization from November 2017 to June 2018. INTERVENTIONS Baseline ventilatory, hemodynamic and neuromonitoring variables were collected immediately before PEEP changes and during the following 30 min. MAIN VARIABLES OF INTEREST PEEP and ICP changes. RESULTS One-hundred and nine patients were included. Mean age was 52.68 (15.34) years, male 71 (65.13%). Traumatic brain injury was the cause of ABI in 54 (49.54%) patients. Length of mechanical ventilation was 16.52 (9.23) days. In-hospital mortality was 21.1%. PEEP increases (mean 6.24-9.10 cmH2O) resulted in ICP increase from 10.4 to 11.39 mmHg, P < .001, without changes in cerebral perfusion pressure (CPP) (P = .548). PEEP decreases (mean 8.96 to 6.53 cmH2O) resulted in ICP decrease from 10.5 to 9.62 mmHg (P = .052), without changes in CPP (P = .762). Significant correlations were established between the increase of ICP and the delta PEEP (R = 0.28, P < .001), delta driving pressure (R = 0.15, P = .038) and delta compliance (R = -0.14, P = .052). ICP increment was higher in patients with lower baseline ICP. CONCLUSIONS PEEP changes were not associated with clinically relevant modifications in ICP values in ABI patients. The magnitude of the change in ICP after PEEP increase was correlated with the delta of PEEP, the delta driving pressure and the delta compliance.
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Affiliation(s)
- Jesús Abelardo Barea-Mendoza
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Zaira Molina-Collado
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - María Ángeles Ballesteros-Sanz
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Luisa Corral-Ansa
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Maite Misis Del Campo
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Cándido Pardo-Rey
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Juan Angel Tihista-Jiménez
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carmen Corcobado-Márquez
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Pedro Martín Del Rincón
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan Antonio Llompart-Pou
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Luis Alfonso Marcos-Prieto
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ander Olazabal-Martínez
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Rubén Herrán-Monge
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Ana María Díaz-Lamas
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Mario Chico-Fernández
- Intensive Medicine Department, UCI de Trauma y Emergencias, UCITE, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [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: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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Fenerci A, Akcil EF, Tunali Y, Dilmen OK. Effect of different positive end expiratory pressure levels on optic nerve sheath diameter in patients with or without midline shift who are undergoing supratentorial craniotomy. Acta Neurochir (Wien) 2024; 166:177. [PMID: 38622368 PMCID: PMC11018676 DOI: 10.1007/s00701-024-06067-1] [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: 11/29/2023] [Accepted: 03/26/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE In general, high levels of PEEP application is avoided in patients undergoing craniotomy to prevent a rise in ICP. But that approach would increase the risk of secondary brain injury especially in hypoxemic patients. Because the optic nerve sheath is distensible, a rise in ICP is associated with an increase in the optic nerve sheath diameter (ONSD). The cutoff value for elevated ICP assessed by ONSD is between 5.6 and 6.3 mm. We aimed to evaluate the effect of different PEEP levels on ONSD and compare the effect of different PEEP levels in patients with and without intracranial midline shift. METHODS This prospective observational study was performed in aged 18-70 years, ASA I-III, 80 patients who were undergoing supratentorial craniotomy. After the induction of general anesthesia, the ONSD's were measured by the linear transducer from 3 mm below the globe at PEEP values of 0-5-10 cmH2O. The ONSD were compered between patients with (n = 7) and without midline shift (n = 73) at different PEEP values. RESULTS The increases in ONSD due to increase in PEEP level were determined (p < 0.001). No difference was found in the comparison of ONSD between patients with and without midline shift in different PEEP values (p = 0.329, 0.535, 0.410 respectively). But application of 10 cmH2O PEEP in patients with a midline shift increased the mean ONSD value to 5.73 mm. This value is roughly 0.1 mm higher than the lower limit of the ONSD cutoff value. CONCLUSIONS The ONSD in adults undergoing supratentorial tumor craniotomy, PEEP values up to 5 cmH2O, appears not to be associated with an ICP increase; however, the ONSD exceeded the cutoff for increased ICP when a PEEP of 10 cmH2O was applied in patients with midline shift.
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Affiliation(s)
- Adem Fenerci
- Department of Anaesthesia & Intensive Care, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, University of Istanbul, 34098, Cerrahpasa, Istanbul, Turkey
| | - Eren Fatma Akcil
- Department of Anaesthesia & Intensive Care, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, University of Istanbul, 34098, Cerrahpasa, Istanbul, Turkey
| | - Yusuf Tunali
- Department of Anaesthesia & Intensive Care, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, University of Istanbul, 34098, Cerrahpasa, Istanbul, Turkey
| | - Ozlem Korkmaz Dilmen
- Department of Anaesthesia & Intensive Care, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, University of Istanbul, 34098, Cerrahpasa, Istanbul, Turkey.
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Zunino G, Battaglini D, Godoy DA. Effects of positive end-expiratory pressure on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in acute brain injury: Friend or foe? A scoping review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:247-260. [PMID: 38681785 PMCID: PMC11043646 DOI: 10.1016/j.jointm.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/27/2023] [Accepted: 08/05/2023] [Indexed: 05/01/2024]
Abstract
Background Patients with acute brain injury (ABI) are a peculiar population because ABI does not only affect the brain but also other organs such as the lungs, as theorized in brain-lung crosstalk models. ABI patients often require mechanical ventilation (MV) to avoid the complications of impaired respiratory function that can follow ABI; MV should be settled with meticulousness owing to its effects on the intracranial compartment, especially regarding positive end-expiratory pressure (PEEP). This scoping review aimed to (1) describe the physiological basis and mechanisms related to the effects of PEEP in ABI; (2) examine how clinical research is conducted on this topic; (3) identify methods for setting PEEP in ABI; and (4) investigate the impact of the application of PEEP in ABI on the outcome. Methods The five-stage paradigm devised by Peters et al. and expanded by Arksey and O'Malley, Levac et al., and the Joanna Briggs Institute was used for methodology. We also adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension criteria. Inclusion criteria: we compiled all scientific data from peer-reviewed journals and studies that discussed the application of PEEP and its impact on intracranial pressure, cerebral perfusion pressure, and brain oxygenation in adult patients with ABI. Exclusion criteria: studies that only examined a pediatric patient group (those under the age of 18), experiments conducted solely on animals; studies without intracranial pressure and/or cerebral perfusion pressure determinations, and studies with incomplete information. Two authors searched and screened for inclusion in papers published up to July 2023 using the PubMed-indexed online database. Data were presented in narrative and tubular form. Results The initial search yielded 330 references on the application of PEEP in ABI, of which 36 met our inclusion criteria. PEEP has recognized beneficial effects on gas exchange, but it produces hemodynamic changes that should be predicted to avoid undesired consequences on cerebral blood flow and intracranial pressure. Moreover, the elastic properties of the lungs influence the transmission of the forces applied by MV over the brain so they should be taken into consideration. Currently, there are no specific tools that can predict the effect of PEEP on the brain, but there is an established need for a comprehensive monitoring approach for these patients, acknowledging the etiology of ABI and the measurable variables to personalize MV. Conclusion PEEP can be safely used in patients with ABI to improve gas exchange keeping in mind its potentially harmful effects, which can be predicted with adequate monitoring supported by bedside non-invasive neuromonitoring tools.
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Affiliation(s)
- Greta Zunino
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Diagnostiche e Chirurgiche Integrate, Università degli Studi di Genova, Genova, Italy
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [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: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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Price AD, Baucom MR, Blakeman TC, Smith M, Gomaa D, Caskey C, Pritts T, Strilka R, Branson RD, Goodman MD. Just Say NO: Inhaled Nitric Oxide Effect on Respiratory Parameters Following Traumatic Brain Injury in Humans and a Porcine Model. J Surg Res 2024; 296:497-506. [PMID: 38325012 DOI: 10.1016/j.jss.2023.12.045] [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: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 02/09/2024]
Abstract
INTRODUCTION The mechanism of post-traumatic brain injury (TBI) hypoxemia involves ventilation/perfusion mismatch and loss of pulmonary hypoxic vasoconstriction. Inhaled nitric oxide (iNO) has been studied as an adjunct treatment to avoid the use of high positive end-expiratory pressure and inspired oxygen in treatment-refractory hypoxia. We hypothesized that iNO treatment following TBI would improve systemic and cerebral oxygenation via improved matching of pulmonary perfusion and ventilation. METHODS Thirteen human patients with isolated TBI were enrolled and randomized to receive either placebo or iNO with measured outcomes including pulmonary parameters, blood gas data, and intracranial pressure (ICP) /perfusion. To complement this study, a porcine model of TBI (including 10 swine) was utilized with measured outcomes of brain tissue blood flow and oxygenation, ventilator parameters, and blood gas data both after administration and following drug removal and clearance. RESULTS There were no clinically significant changes in pulmonary parameters in either the human or porcine arm following administration of iNO when compared to either the placebo group (human arm) or the internal control (porcine arm). Analysis of pooled human data demonstrated the preservation of alveolar recruitment in TBI patients. There were no clinically significant changes in human ICP or cerebral perfusion pressure following iNO administration compared to controls. CONCLUSIONS iNO had no significant effect on clinically relevant pulmonary parameters or ICPs following TBI in both human patients and a porcine model. The pressure-based recruitment of the human lungs following TBI was preserved. Further investigation will be needed to determine the degree of utility of iNO in the setting of hypoxia after polytrauma.
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Affiliation(s)
- Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Maia Smith
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dina Gomaa
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Chelsea Caskey
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Timothy Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Richard Strilka
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Zhao L, Lv S, Xiao Q, Zhang Y, Yi W, Bai Y, Lu K, Bermea KC, Semel J, Yang X, Wu J. Effects of positive end-expiratory pressure on regional cerebral oxygen saturation in elderly patients undergoing thoracic surgery during one-lung ventilation: a randomized crossover-controlled trial. BMC Pulm Med 2024; 24:120. [PMID: 38448844 PMCID: PMC10919006 DOI: 10.1186/s12890-024-02931-z] [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: 09/23/2023] [Accepted: 02/24/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND A significant reduction in regional cerebral oxygen saturation (rSO2) is commonly observed during one-lung ventilation (OLV), while positive end-expiratory pressure (PEEP) can improve oxygenation. We compared the effects of three different PEEP levels on rSO2, pulmonary oxygenation, and hemodynamics during OLV. METHODS Forty-three elderly patients who underwent thoracoscopic lobectomy were randomly assigned to one of six PEEP combinations which used a crossover design of 3 levels of PEEP-0 cmH2O, 5 cmH2O, and 10 cmH2O. The primary endpoint was rSO2 in patients receiving OLV 20 min after adjusting the PEEP. The secondary outcomes included hemodynamic and respiratory variables. RESULTS After exclusion, thirty-six patients (36.11% female; age range: 60-76 year) were assigned to six groups (n = 6 in each group). The rSO2 was highest at OLV(0) than at OLV(10) (difference, 2.889%; [95% CI, 0.573 to 5.204%]; p = 0.008). Arterial oxygen partial pressure (PaO2) was lowest at OLV(0) compared with OLV(5) (difference, -62.639 mmHg; [95% CI, -106.170 to -19.108 mmHg]; p = 0.005) or OLV(10) (difference, -73.389 mmHg; [95% CI, -117.852 to -28.925 mmHg]; p = 0.001), while peak airway pressure (Ppeak) was lower at OLV(0) (difference, -4.222 mmHg; [95% CI, -5.140 to -3.304 mmHg]; p < 0.001) and OLV(5) (difference, -3.139 mmHg; [95% CI, -4.110 to -2.167 mmHg]; p < 0.001) than at OLV(10). CONCLUSIONS PEEP with 10 cmH2O makes rSO2 decrease compared with 0 cmH2O. Applying PEEP with 5 cmH2O during OLV in elderly patients can improve oxygenation and maintain high rSO2 levels, without significantly increasing peak airway pressure compared to not using PEEP. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2200060112 on 19 May 2022.
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Affiliation(s)
- Liying Zhao
- Department of Anesthesiology, Qilu Hospital of Shandong University, 107 #, Wenhua Xi Road, 250012, Jinan, Shandong, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, 250012, Jinan, China
| | - Shuang Lv
- Department of Anesthesiology, Qilu Hospital of Shandong University, 107 #, Wenhua Xi Road, 250012, Jinan, Shandong, China
- School of Medicine, Cheeloo College of Medicine, Shandong University, 250012, Jinan, China
| | - Qian Xiao
- Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, 445000, Enshi City, Hubei Province, China
| | - Yuan Zhang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, 250012, Jinan, Shandong, China
| | - Wenbo Yi
- Department of Anesthesiology, Qilu Hospital of Shandong University, 107 #, Wenhua Xi Road, 250012, Jinan, Shandong, China
| | - Yu Bai
- School of Medicine, Cheeloo College of Medicine, Shandong University, 250012, Jinan, China
| | - Kangping Lu
- School of Medicine, Cheeloo College of Medicine, Shandong University, 250012, Jinan, China
| | - Kevin C Bermea
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, 21205, Baltimore, MD, USA
| | - Jessica Semel
- Department of Biochemistry and Molecular Biology, Center for Research on Cardiac Intermediate Filaments, Johns Hopkins University School of Medicine, 21205, Baltimore, MD, USA
| | - Xiaomei Yang
- Department of Anesthesiology, Qilu Hospital of Shandong University, 107 #, Wenhua Xi Road, 250012, Jinan, Shandong, China.
- School of Medicine, Cheeloo College of Medicine, Shandong University, 250012, Jinan, China.
| | - Jianbo Wu
- School of Medicine, Cheeloo College of Medicine, Shandong University, 250012, Jinan, China.
- Department of Anesthesiology and Perioperative Medicine, Shandong Institute of Anesthesia and Respiratory Critical Medicine, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, 16766 #, Jingshi Road, 250012, Jinan, Shandong, China.
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Joseph A, Petit M, Vieillard-Baron A. Hemodynamic effects of positive end-expiratory pressure. Curr Opin Crit Care 2024; 30:10-19. [PMID: 38085886 DOI: 10.1097/mcc.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW Positive end-expiratory pressure (PEEP) is required in the Berlin definition of acute respiratory distress syndrome and is a cornerstone of its treatment. Application of PEEP increases airway pressure and modifies pleural and transpulmonary pressures according to respiratory mechanics, resulting in blood volume alteration into the pulmonary circulation. This can in turn affect right ventricular preload, afterload and function. At the opposite, PEEP may improve left ventricular function, providing no deleterious effect occurs on the right ventricle. RECENT FINDINGS This review examines the impact of PEEP on cardiac function with regards to heart-lung interactions, and describes its consequences on organs perfusion and function, including the kidney, gut, liver and the brain. PEEP in itself is not beneficious nor detrimental on end-organ hemodynamics, but its hemodynamic effects vary according to both respiratory mechanics and association with other hemodynamic variables such as central venous or mean arterial pressure. There are parallels in the means of preventing deleterious impact of PEEP on the lungs, heart, kidney, liver and central nervous system. SUMMARY The quest for optimal PEEP settings has been a prominent goal in ARDS research for the last decades. Intensive care physician must maintain a high degree of vigilance towards hemodynamic effects of PEEP on cardiac function and end-organs circulation.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt
| | - Matthieu Petit
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt
- Inserm, CESP, Paris-Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
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Gouvea Bogossian E, Cantos J, Farinella A, Nobile L, Njimi H, Coppalini G, Diosdado A, Salvagno M, Oliveira Gomes F, Schuind S, Anderloni M, Robba C, Taccone FS. The effect of increased positive end expiratory pressure on brain tissue oxygenation and intracranial pressure in acute brain injury patients. Sci Rep 2023; 13:16657. [PMID: 37789100 PMCID: PMC10547811 DOI: 10.1038/s41598-023-43703-9] [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: 08/08/2023] [Accepted: 09/27/2023] [Indexed: 10/05/2023] Open
Abstract
Cerebral hypoxia is an important cause of secondary brain injury. Improving systemic oxygenation may increase brain tissue oxygenation (PbtO2). The effects of increased positive end-expiratory pressure (PEEP) on PbtO2 and intracranial pressure (ICP) needs to be further elucidated. This is a single center retrospective cohort study (2016-2021) conducted in a 34-bed Department of Intensive Care unit. All patients with acute brain injury under mechanical ventilation who were monitored with intracranial pressure and brain tissue oxygenation (PbtO2) catheters and underwent at least one PEEP increment were included in the study. Primary outcome was the rate of PbtO2 responders (increase in PbtO2 > 20% of baseline) after PEEP increase. ΔPEEP was defined as the difference between PEEP at 1 h and PEEP at baseline; similarly ΔPbtO2 was defined as the difference between PbtO2 at 1 h after PEEP incrementation and PbtO2 at baseline. We included 112 patients who underwent 295 episodes of PEEP increase. Overall, the median PEEP increased form 6 (IQR 5-8) to 10 (IQR 8-12) cmH2O (p = 0.001), the median PbtO2 increased from 21 (IQR 16-29) mmHg to 23 (IQR 18-30) mmHg (p = 0.001), while ICP remained unchanged [from 12 (7-18) mmHg to 12 (7-17) mmHg; p = 0.42]. Of 163 episode of PEEP increments with concomitant PbtO2 monitoring, 34 (21%) were PbtO2 responders. A lower baseline PbtO2 (OR 0.83 [0.73-0.96)]) was associated with the probability of being responder. ICP increased in 142/295 episodes of PEEP increments (58%); no baseline variable was able to identify this response. In PbtO2 responders there was a moderate positive correlation between ΔPbtO2 and ΔPEEP (r = 0.459 [95% CI 0.133-0.696]. The response in PbtO2 and ICP to PEEP elevations in brain injury patients is highly variable. Lower PbtO2 values at baseline could predict a significant increase in brain oxygenation after PEEP increase.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Joaquin Cantos
- Critical Care Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Anita Farinella
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Hassane Njimi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giacomo Coppalini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Alberto Diosdado
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fernando Oliveira Gomes
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Université Libre de Bruxelles, Brussels, Belgium
| | - Marco Anderloni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, IRCCS Policlinico San Martino, Università di Genova, Genova, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
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Torre Oñate T, Romero Berrocal A, Bilotta F, Badenes R, Santos Gonzalez M, de Reina Perez L, Garcia Fernandez J. Impact of Stepwise Recruitment Maneuvers on Cerebral Hemodynamics: Experimental Study in Neonatal Model. J Pers Med 2023; 13:1184. [PMID: 37623435 PMCID: PMC10456108 DOI: 10.3390/jpm13081184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Lung recruitment maneuvers (LRMs) have been demonstrated to be effective in avoiding atelectasis during general anesthesia in the pediatric population. Performing these maneuvers is safe at the systemic hemodynamic and respiratory levels. AIMS We aimed to evaluate the impact of a stepwise LRM and individualized positive end-expiratory pressure (PEEP) on cerebral hemodynamics in an experimental neonatal model. METHODS Eleven newborn pigs (less than 72 h old, 2.56 ± 0.18 kg in weight) were included in the study. The LRM was performed under pressure-controlled ventilation with a constant driving pressure (15 cmH2O) in a stepwise increasing PEEP model. The target peak inspiratory pressure (PIP) was 30 cmH2O and the PEEP was 15 cmH2O. The following hemodynamic variables were monitored using the PICCO® system: mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO). The cerebral hemodynamics variables monitored were intracranial pressure (ICP) (with an intraparenchymal Camino® catheter) and cerebral oxygen saturation (rSO2) (with the oximetry monitor INVOS 5100® system). The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen, end-tidal carbon dioxide pressure, Pmean, PEEP, static compliance (Cstat), and dynamic compliance (Cdyn). RESULTS All LRMs were safely performed as scheduled without any interruptions. Systemic hemodynamic stability was maintained during the lung recruitment maneuver. No changes in ICP occurred. We observed an improvement in rSO2 after the maneuver (+5.8%). CONCLUSIONS Stepwise LRMs are a safe tool to avoid atelectasis. We did not observe an impairment in cerebral hemodynamics but an improvement in cerebral oxygenation.
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Affiliation(s)
- Teresa Torre Oñate
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, 28222 Majadahonda, Spain; (A.R.B.); (J.G.F.)
| | - Antonio Romero Berrocal
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, 28222 Majadahonda, Spain; (A.R.B.); (J.G.F.)
| | - Federico Bilotta
- Department of Anaesthesiology and Intensive Care, Sapienza University of Rome, 00185 Rome, Italy;
| | - Rafael Badenes
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Clinic Universitari en Valencia, University of Valencia, 46010 Valencia, Spain;
| | - Martin Santos Gonzalez
- Medical and Surgical Research Unit, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Hospital Universitario Puerta de Hierro en Majadahonda, 28222 Majadahonda, Spain;
| | - Laura de Reina Perez
- Department of Neurosurgery, Hospital Universitario Puerta de Hierro en Majadahonda, 28222 Majadahonda, Spain;
| | - Javier Garcia Fernandez
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, 28222 Majadahonda, Spain; (A.R.B.); (J.G.F.)
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Taran S, Wahlster S, Robba C. Ventilatory targets following brain injury. Curr Opin Crit Care 2023; 29:41-49. [PMID: 36762685 DOI: 10.1097/mcc.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Recent studies have focused on identifying optimal targets and strategies of mechanical ventilation in patients with acute brain injury (ABI). The present review will summarize these findings and provide practical guidance to titrate ventilatory settings at the bedside, with a focus on managing potential brain-lung conflicts. RECENT FINDINGS Physiologic studies have elucidated the impact of low tidal volume ventilation and varying levels of positive end expiratory pressure on intracranial pressure and cerebral perfusion. Epidemiologic studies have reported the association of different thresholds of tidal volume, plateau pressure, driving pressure, mechanical power, and arterial oxygen and carbon dioxide concentrations with mortality and neurologic outcomes in patients with ABI. The data collectively make clear that injurious ventilation in this population is associated with worse outcomes; however, optimal ventilatory targets remain poorly defined. SUMMARY Although direct data to guide mechanical ventilation in brain-injured patients is accumulating, the current evidence base remains limited. Ventilatory considerations in this population should be extrapolated from high-quality evidence in patients without brain injury - keeping in mind relevant effects on intracranial pressure and cerebral perfusion in patients with ABI and individualizing the chosen strategy to manage brain-lung conflicts where necessary.
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Affiliation(s)
- Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard University, Boston, MA, USA
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Wahlster
- Department of Neurology
- Department of Neurological Surgery
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Chiara Robba
- IRCCS, Policlinico San Martino
- Department of Surgical Sciences and Diagnostic Integrated, University of Genoa, Genoa, Italy
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12
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Beqiri E, Smielewski P, Guérin C, Czosnyka M, Robba C, Bjertnæs L, Frisvold SK. Neurological and respiratory effects of lung protective ventilation in acute brain injury patients without lung injury: brain vent, a single centre randomized interventional study. Crit Care 2023; 27:115. [PMID: 36941683 PMCID: PMC10026451 DOI: 10.1186/s13054-023-04383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Lung protective ventilation (LPV) comprising low tidal volume (VT) and high positive end-expiratory pressure (PEEP) may compromise cerebral perfusion in acute brain injury (ABI). In patients with ABI, we investigated whether LPV is associated with increased intracranial pressure (ICP) and/or deranged cerebral autoregulation (CA), brain compensatory reserve and oxygenation. METHODS In a prospective, crossover study, 30 intubated ABI patients with normal ICP and no lung injury were randomly assigned to receive low VT [6 ml/kg/predicted (pbw)]/at either low (5 cmH2O) or high PEEP (12 cmH2O). Between each intervention, baseline ventilation (VT 9 ml/kg/pbw and PEEP 5 cmH2O) were resumed. The safety limit for interruption of the intervention was ICP above 22 mmHg for more than 5 min. Airway and transpulmonary pressures were continuously monitored to assess respiratory mechanics. We recorded ICP by using external ventricular drainage or a parenchymal probe. CA and brain compensatory reserve were derived from ICP waveform analysis. RESULTS We included 27 patients (intracerebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage), of whom 6 reached the safety limit, which required interruption of at least one intervention. For those without intervention interruption, the ICP change from baseline to "low VT/low PEEP" and "low VT/high PEEP" were 2.2 mmHg and 2.3 mmHg, respectively, and considered clinically non-relevant. None of the interventions affected CA or oxygenation significantly. Interrupted events were associated with high baseline ICP (p < 0.001), low brain compensatory reserve (p < 0.01) and mechanical power (p < 0.05). The transpulmonary driving pressure was 5 ± 2 cmH2O in both interventions. Partial arterial pressure of carbon dioxide was kept in the range 34-36 mmHg by adjusting the respiratory rate, hence, changes in carbon dioxide were not associated with the increase in ICP. CONCLUSIONS The present study found that most patients did not experience any adverse effects of LPV, neither on ICP nor CA. However, in almost a quarter of patients, the ICP rose above the safety limit for interrupting the interventions. Baseline ICP, brain compensatory reserve, and mechanical power can predict a potentially deleterious effect of LPV and can be used to personalize ventilator settings. Trial registration NCT03278769 . Registered September 12, 2017.
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Affiliation(s)
- Erta Beqiri
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Claude Guérin
- University of Lyon, Lyon, France
- INSERM955, Créteil, France
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience, Policlinico San Martino, Genoa, Italy
- Department of Surgical Science Diagnostic and Integrated, University of Genova, Genoa, Italy
| | - Lars Bjertnæs
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Shirin K Frisvold
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway.
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
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13
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Mechanical Ventilation in Patients with Traumatic Brain Injury: Is it so Different? Neurocrit Care 2023; 38:178-191. [PMID: 36071333 DOI: 10.1007/s12028-022-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/16/2022] [Indexed: 10/14/2022]
Abstract
Patients with traumatic brain injury (TBI) frequently require invasive mechanical ventilation and admission to an intensive care unit. Ventilation of patients with TBI poses unique clinical challenges, and careful attention is required to ensure that the ventilatory strategy (including selection of appropriate tidal volume, plateau pressure, and positive end-expiratory pressure) does not cause significant additional injury to the brain and lungs. Selection of ventilatory targets may be guided by principles of lung protection but with careful attention to relevant intracranial effects. In patients with TBI and concomitant acute respiratory distress syndrome (ARDS), adjunctive strategies include sedation optimization, neuromuscular blockade, recruitment maneuvers, prone positioning, and extracorporeal life support. However, these approaches have been largely extrapolated from studies in patients with ARDS and without brain injury, with limited data in patients with TBI. This narrative review will summarize the existing evidence for mechanical ventilation in patients with TBI. Relevant literature in patients with ARDS will be summarized, and where available, direct data in the TBI population will be reviewed. Next, practical strategies to optimize the delivery of mechanical ventilation and determine readiness for extubation will be reviewed. Finally, future directions for research in this evolving clinical domain will be presented, with considerations for the design of studies to address relevant knowledge gaps.
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Zhou D, Li T, Fei S, Wang C, Lv Y. The effect of positive end-expiratory pressure on intracranial pressure in obese and non-obese severe brain injury patients: a retrospective observational study. BMC Anesthesiol 2022; 22:388. [PMID: 36522657 PMCID: PMC9753360 DOI: 10.1186/s12871-022-01934-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) had never been studied in obese patients with severe brain injury (SBI). The main aim was to evaluate the effect of PEEP on ICP in SBI patients with mechanical ventilation according to obesity status. METHODS SBI patients admitted to the ICU with mechanical ventilation between 2014 and 2015 were included. Demographic, hemodynamic, arterial blood gas, and ventilator data at the time of the paired PEEP and ICP observations were recorded and compared between obese (body mass index ≥ 30 kg/m2) and non-obese SBI patients. Generalized estimating equation (GEE) model was used to assess the relationship between PEEP and ICP in obese and non-obese SBI patients, respectively. RESULTS Six hundred twenty-seven SBI patients were included, 407 (65%) non-obese and 220 (35%) obese patients. A total of 30,415 paired PEEP and ICP observations were recorded in these patients, 19,566 (64.3%) for non-obese and 10,849 (35.7%) for obese. In the multivariable analysis, a statistically significant relationship between PEEP and ICP was found in obese SBI patients, but not in non-obese ones. For every cmH2O increase in PEEP, there was a 0.19 mmHg increase in ICP (95% CI [0.05, 0.33], P = 0.007) and a 0.15 mmHg decrease in CPP (95% CI [-0.29, -0.01], P = 0.036) in obese SBI patients after adjusting for confounders. CONCLUSIONS The results suggested that, contrary to non-obese SBI patients, the application of PEEP may produce an increase in ICP in obese SBI patients. However, the effect was modest and may be clinically inconsequential.
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Affiliation(s)
- Dawei Zhou
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Tong Li
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Shuyang Fei
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yi Lv
- grid.24696.3f0000 0004 0369 153XDepartment of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Maslonka MA, Sheehan KN, Datar SV, Vachharajani V, Namen A. Pathophysiology and Management of Neurogenic Pulmonary Edema in Patients with Acute Severe Brain Injury. South Med J 2022; 115:784-789. [DOI: 10.14423/smj.0000000000001457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Fan TH, Huang M, Price C, Premraj L, Kannapadi NV, Suarez JI, Cho SM. Prevalence and outcomes of acute respiratory distress syndrome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. JOURNAL OF NEUROCRITICAL CARE 2022. [DOI: 10.18700/jnc.220043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: In this study, we aimed to investigate the prevalence, timing, risk factors, and outcomes of acute respiratory distress syndrome (ARDS) in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: PubMed and four other databases were searched for randomized controlled trials (RCTs) and observational studies of patients 18 years or older through October 20, 2021. Study quality was assessed, using the Cochrane Risk of Bias tool for RCTs and the Newcastle-Ottawa Scale for cohort and case-control studies. High-grade aSAH was defined as a Hunt-Hess grade≥3 and/or a modified Fisher score≥3. A good neurological outcome was defined as a Glasgow Outcome Scale score ≥4. Random-effects meta-analyses were conducted to estimate the pooled outcome prevalence and 95% confidence interval (CI). Results: Eleven observational studies (n=6,107) met the inclusion criteria. Overall, 15% of the patients (95% CI=10.5–20.0; I2=97.8%) developed ARDS after aSAH, with a mean time of 3 days (95% CI=1.9–3.7; I2=54%). Overall survival at discharge was 80% (95% CI=75–86; I2=96%), and 67% of aSAH patients (95% CI=54.9–78.9; I2=94%) had a good neurological outcome at any time. The aSAH cohort without ARDS had a higher rate of survival than those with ARDS (79% vs. 49%, P=0.028). Male sex, patients with a high-grade aSAH, patients who developed pneumonia, and systemic inflammatory response syndrome during hospital admission were at a higher risk of developing ARDS.Conclusion: In this meta-analysis, approximately one in six patients developed ARDS after aSAH, with a mean time of 3 days from the initial presentation, and ARDS was associated with increased mortality.
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Focused Management of Patients With Severe Acute Brain Injury and ARDS. Chest 2022; 161:140-151. [PMID: 34506794 PMCID: PMC8423666 DOI: 10.1016/j.chest.2021.08.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 02/04/2023] Open
Abstract
Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.
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19
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Balakrishnan S, Naik S, Chakrabarti D, Konar S, Sriganesh K. Effect of Respiratory Physiological Changes on Optic Nerve Sheath Diameter and Cerebral Oxygen Saturation in Patients With Acute Traumatic Brain Injury. J Neurosurg Anesthesiol 2022; 34:e52-e56. [PMID: 32555065 DOI: 10.1097/ana.0000000000000706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe traumatic brain injury (TBI) results in raised intracranial pressure (ICP). Ultrasonographic measurement of the optic nerve sheath diameter (ONSD) is a noninvasive method for the assessment of raised ICP. Manipulation of positive end-expiratory pressure (PEEP) and end-tidal carbon dioxide (ETCO2) are often used to optimize ICP and improve oxygenation in TBI patients. This study evaluated the effects of PEEP and ETCO2 on ONSD and regional cerebral oxygen saturation (rScO2) in patients with acute TBI. METHODS A total of 14 patients (11 males) aged older than 18 years with acute severe TBI were included in this study. ONSD and rScO2 were assessed before and after changes in PEEP from 5 to 10 cm H2O and in ETCO2 from 40 to 30 mm Hg on both pathologic and nonpathologic sides. RESULTS Increasing PEEP and reducing ETCO2 resulted in changes in ONSD and rScO2 on both pathologic and nonpathologic sides. On the pathologic side, ONSD and rScO2 were highest with a PEEP of 10 cm H2O:ETCO2 40 mm Hg combination and lowest with PEEP of 5 cm H2O:ETCO2 30 mm Hg (ONSD 5.24±0.49 vs. 4.27±0.36 mm, P<0.001; rScO2 70.7±9.91% vs. 66.3±9.75%, P<0.001); both PEEP and ETCO2 had significant effects on ONSD and rScO2 (P<0.001). On the nonpathologic side, ONSD and rScO2 were highest and lowest with PEEP of 10 cm H2O:ETCO2 40 mm Hg and PEEP of 5 cm H2O:ETCO2 30 mm Hg combinations, respectively (ONSD: 4.93±0.46 vs. 4.02±0.40 mm, P<0.001; rScO2: 74.77±8.30% vs. 70.69±8.12%, P<0.001). ETCO2 had a significant effect on rScO2 (P<0.001), but the impact of PEEP on rScO2 was not statistically significant (P=0.05). CONCLUSION Increasing PEEP resulted in significant increases in ONSD and rScO2, whereas reducing ETCO2 significantly decreased ONSD and rScO2.
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Affiliation(s)
- Sweatha Balakrishnan
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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20
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Chen H, Zhou XF, Zhou DW, Zhou JX, Yu RG. Effect of increased positive end-expiratory pressure on intracranial pressure and cerebral oxygenation: impact of respiratory mechanics and hypovolemia. BMC Neurosci 2021; 22:72. [PMID: 34823465 PMCID: PMC8614026 DOI: 10.1186/s12868-021-00674-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the impact of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) in animals with different respiratory mechanics, baseline ICP and volume status. METHODS A total of 50 male adult Bama miniature pigs were involved in four different protocols (n = 20, 12, 12, and 6, respectively). Under the monitoring of ICP, brain tissue oxygen tension and hemodynamical parameters, PEEP was applied in increments of 5 cm H2O from 5 to 25 cm H2O. Measurements were taken in pigs with normal ICP and normovolemia (Series I), or with intracranial hypertension (via inflating intracranial balloon catheter) and normovolemia (Series II), or with intracranial hypertension and hypovolemia (via exsanguination) (Series III). Pigs randomized to the control group received only hydrochloride instillation while the intervention group received additional chest wall strapping. Common carotid arterial blood flow before and after exsanguination at each PEEP level was measured in pigs with intracranial hypertension and chest wall strapping (Series IV). RESULTS ICP was elevated by increased PEEP in both normal ICP and intracranial hypertension conditions in animals with normal blood volume, while resulted in decreased ICP with PEEP increments in animals with hypovolemia. Increasing PEEP resulted in a decrease in brain tissue oxygen tension in both normovolemic and hypovolemic conditions. The impacts of PEEP on hemodynamical parameters, ICP and brain tissue oxygen tension became more evident with increased chest wall elastance. Compare to normovolemic condition, common carotid arterial blood flow was further lowered when PEEP was raised in the condition of hypovolemia. CONCLUSIONS The impacts of PEEP on ICP and cerebral oxygenation are determined by both volume status and respiratory mechanics. Potential conditions that may increase chest wall elastance should also be ruled out to avoid the deleterious effects of PEEP.
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Affiliation(s)
- Han Chen
- Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China.,Department of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Xiao-Fen Zhou
- Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China.,Department of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China
| | - Da-Wei Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong-Guo Yu
- Fujian Shengli Clinical Medical College, Fujian Medical University, Fuzhou, China. .,Department of Critical Care Medicine, Fujian Provincial Hospital, Fuzhou, China.
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Gupta N, Singh VK, Jafa S. Correlation of Positive End-Expiratory and Intracranial Pressure Using the Ultrasonographic-Guided Measurement of Optic Nerve Sheath Diameter in Traumatic Brain Injury Patients. Neurol India 2021; 69:1670-1674. [PMID: 34979667 DOI: 10.4103/0028-3886.333532] [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: 11/04/2022]
Abstract
BACKGROUND In brain injury patients, positive end-expiratory pressure (PEEP) may potentially increase the intracranial pressure (ICP). ICP can be noninvasively assessed from the sonographic measurement of the optic nerve sheath diameter (ONSD). Herein, we aim to evaluate the association between PEEP and ICP via measuring ONSD in traumatic brain injury (TBI) patients. METHODS TBI patients with age ≥18 years, severe brain injury (GCS 8 or less), receiving mechanical ventilation, initial PEEP ≤4 mmHg and no history of severe cardiopulmonary disease were included in this study. Patients with intracranial hypertension (defined as ICP >20 mmHg) and already receiving PEEP >15 cm H2O at enrollment were excluded from the study. ONSD measurement was performed when hemodynamic parameters were most stable. Variables included central venous pressure, invasive blood pressure, heart rate, saturation, and ventilator parameters. RESULTS The ONSD and ICP did not increase significantly while PEEP increased from 0-5 cm and 5-10 cm H2O. However, ONSD and ICP significantly increased when PEEP increased from 10-15 cm H2O. There was no significant difference noted while comparing measurements of optic nerve sheath (ONS) diameter in both eyes at all PEEP values in cases as well as control patients. Mean arterial pressure (MAP) decreased with an increase in PEEP value. Highly significant decrease occurred in MAP change from PEEP 10-15 in cases (P < 0.001) and control (P < 0.001). CONCLUSIONS The PEEP up to 10 cm H2O can be safely applied in patients with TBI. In addition, the increment of PEEP might further increase the oxygenation, at the cost of ICP accentuation.
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Affiliation(s)
- Neha Gupta
- Department of Anesthesiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Vipin K Singh
- Department of Anesthesiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Shobhna Jafa
- Department of Anesthesiology, KGMU, Lucknow, Uttar Pradesh, India
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Ziaka M, Exadaktylos A. Brain-lung interactions and mechanical ventilation in patients with isolated brain injury. Crit Care 2021; 25:358. [PMID: 34645485 PMCID: PMC8512596 DOI: 10.1186/s13054-021-03778-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022] Open
Abstract
During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.
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Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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Lomeli M, Dominguez Cenzano L, Torres L, Chavarría U, Poblano M, Tendillo F, Blanch L, Mancebo J. Reclutamiento alveolar agresivo en el SDRA: más sombras que luces. Med Intensiva 2021. [DOI: 10.1016/j.medin.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Aggressive alveolar recruitment in ARDS: More shadows than lights. Med Intensiva 2021; 45:431-436. [PMID: 34238723 DOI: 10.1016/j.medine.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/18/2020] [Indexed: 12/16/2022]
Abstract
Alveolar recruitment in acute respiratory distress syndrome (ARDS) is defined as the penetration of gas into previously unventilated areas or poorly ventilated areas. Alveolar recruitment during recruitment maneuvering (RM) depends on the duration of the maneuver, the recruitable lung tissue, and the balance between the recruitment of collapsed areas and over-insufflation of the ventilated areas. Alveolar recruitment is estimated using computed tomography of the lung and, at the patient bedside, through assessment of the recruited volume using pressure-volume curves and assessing lung morphology with pulmonary ultrasound and/or impedance tomography. The scientific evidence on RM in patients with ARDS remains subject to controversy. Randomized studies on ARDS have shown no benefit or have even reflected an increase in mortality. The routine use of RM is therefore not recommended.
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Lo-Cao E, Hall S, Parsell R, Dandie G, Fahlström A. Neurogenic pulmonary edema. Am J Emerg Med 2020; 45:678.e3-678.e5. [PMID: 33308892 DOI: 10.1016/j.ajem.2020.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022] Open
Abstract
AIM We report a case of neurogenic pulmonary edema in a patient who sustained a severe traumatic brain injury in a motorbike accident and review the current literature with regards to the management of neurogenic pulmonary edema (NPE). METHODS A 17 year old male was involved in a motorbike collision into a tree. Copious amounts of pink frothy sputum was noted on scene. Rapid sequence intubation was performed on scene and video laryngoscopy demonstrated profuse frothy secretions welling up from the larynx. RESULTS The patient underwent emergency external ventricular drain insertion for intracranial pressure (ICP) monitoring. Intracranial pressures remained refractorily high and a decompressive bifrontal craniectomy was performed on the subsequent day. He was tracheostomised on admission day 24 and discharged from ICU on day 34. DISCUSSION Neurogenic pulmonary edema is defined as acute respiratory distress triggered by severe sympathetic discharge from acute compromise in the central nervous system. Rapid intervention with intubation is often necessary to protect the airways and facilitate diagnostic evaluation. Reduction of ICP and supportive mechanical ventilation to improve oxygenation is necessary. Positive end-expiratory pressure should be carefully applied to balance recruitment of alveoli and minimisation of ICP. Although NPE is estimated to resolve within 72 h in more than half of patients, prognosis is generally poor due to the severity of the underlying brain injury, with estimated mortality rates of between 60 and 100%. CONCLUSION Neurogenic pulmonary edema is a potentially life-threatening complication of severe brain injury and should be recognised early to facilitate management.
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Affiliation(s)
- Edward Lo-Cao
- Department of Neurosurgery, Westmead Hospital, Hawkesbury Road, Westmead 2145, New South Wales, Australia; The University of Sydney, Camperdown 2006, New South Wales, Australia.
| | - Samuel Hall
- Department of Neurosurgery, Westmead Hospital, Hawkesbury Road, Westmead 2145, New South Wales, Australia
| | - Ruth Parsell
- Emergency Department, Nepean Hospital, Derby Street, Kingswood 2747, New South Wales, Australia; CareFlight Rapid Response Helicopter, Redbank Road, Northmead 2152, New South Wales, Australia
| | - Gordon Dandie
- Department of Neurosurgery, Westmead Hospital, Hawkesbury Road, Westmead 2145, New South Wales, Australia
| | - Andreas Fahlström
- Department of Neurosurgery, Westmead Hospital, Hawkesbury Road, Westmead 2145, New South Wales, Australia; Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala 75185, Sweden
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Individualized PEEP ventilation between tumor resection and dural suture in craniotomy. Clin Neurol Neurosurg 2020; 196:106027. [PMID: 32673939 DOI: 10.1016/j.clineuro.2020.106027] [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: 03/16/2020] [Revised: 05/03/2020] [Accepted: 06/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Atelectasis, which affects oxygenation, is always occurred after craniotomy under general anesthesia. The commonly used protective ventilation strategy, which includes recruitment maneuver and higher level of positive end-expiratory pressure (PEEP), can effectively reduce atelectasis after heart and abdominal surgery, but increase intracranial pressure and reduce cerebral perfusion in patients undergoing craniotomy. We hypothesized individualized PEEP ventilation between tumor resection and dural suture in craniotomy could effectively reduce postoperative atelectasis, improve PaO2/FiO2 ratio, and without reducing the regional cerebral oxygen saturation (rScO2). PATIENTS AND METHODS 96 patients underwent tumor craniotomy in supine position were randomized into the control group (C group) and individualized PEEP group (P group). In the C group, the tidal volume (VT) was set at 8 mL/kg of predicted body weight, but PEEP were not used. In the P group, VT was set at 6 mL/kg of predicted body weight combined with individualized PEEP between tumor resection and dural suture, while in other periods of general anesthesia, VT was set at 8 mL/kg of predicted body weight. PaO2/FiO2 ratio, lung ultrasound score (LUS) and rScO2 were measured before induction, 1 h and 24 h after extubation. RESULTS Individual PEEP in the P group was 7.0 (4.0-9.0). The PaO2/FiO2 ratio and rScO2 in the P group were significantly higher than that of the C group (395 ± 62 vs. 344 ± 40, 67 ± 5 vs. 61 ± 4, respectively, p < 0.05) and the LUS of the experimental group was significantly lower than that of the C group [7.5 (5.3-8.3) vs. 10.0 (9.0-12.0), p < 0.05] 1 h after extubation. CONCLUSION Mechanical ventilation with individualized PEEP between tumor resection and dural suture in craniotomy can reduce atelectasis, improve PaO2/FiO2 ratio and rScO2 1 h after extubation.
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Li HP, Lin YN, Cheng ZH, Qu W, Zhang L, Li QY. Intracranial-to-central venous pressure gap predicts the responsiveness of intracranial pressure to PEEP in patients with traumatic brain injury: a prospective cohort study. BMC Neurol 2020; 20:234. [PMID: 32513142 PMCID: PMC7276961 DOI: 10.1186/s12883-020-01764-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/04/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Mechanical ventilation (MV) with positive end-expiratory pressure (PEEP) is commonly applied in patients with severe traumatic brain injury (sTBI). However, the individual responsiveness of intracranial pressure (ICP) to PEEP varies. Thus, identifying an indicator detecting ICP responsiveness to PEEP is of great significance. As central venous pressure (CVP) could act as an intermediary to transduce pressure from PEEP to ICP, we developed a new indicator, PICGap, representing the gap between baseline ICP and baseline CVP. The aim of the current study was to explore the relationship between PICGap and ICP responsiveness to PEEP. METHODS A total of 112 patients with sTBI undergoing MV were enrolled in this prospective cohort study. ICP, CVP, cerebral perfusion pressure (CPP), static compliance of the respiratory system (Cst), and end-tidal carbon dioxide pressure (PetCO2) were recorded at the initial (3 cmH2O) and adjusted (15 cmH2O) levels of PEEP. PICGap was assessed as baseline ICP - baseline CVP (when PEEP = 3 cmH2O). The patients were classified into the ICP responder and non-responder groups based on whether ICP increment with PEEP adjusted from 3 cmH2O to 15 cmH2O was greater than 20% of baseline ICP. The above parameters were compared between the two groups, and prediction of ICP responsiveness to PEEP adjustment was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS Compared with the non-responder group, the responder group had lower PICGap (1.63 ± 1.33 versus 6.56 ± 2.46 mmHg; p < 0.001), lower baseline ICP, and higher baseline CVP. ROC curve analysis suggested that PICGap was a stronger predictive indicator of ICP responsiveness to PEEP (AUC = 0.957, 95%CI 0.918-0.996; p < 0.001) compared with baseline ICP and baseline CVP, with favorable sensitivity (95.24, 95%CI 86.91-98.70%) and specificity (87.6, 95%CI 75.76-94.27%), at a cut off value of 2.5 mmHg. CONCLUSION The impact of PEEP on ICP depends on the gap between baseline ICP and baseline CVP, i.e. PICGap. In addition, PICGap is a potential predictor of ICP responsiveness to PEEP adjustment in patients with sTBI.
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Affiliation(s)
- Hong Peng Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.,Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.,Department of Emergency and Critical Care Medicine, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, People's Republic of China
| | - Ying Ni Lin
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.,Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Zhi Hui Cheng
- Department of Emergency and Critical Care Medicine, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, People's Republic of China
| | - Wei Qu
- Department of Emergency and Critical Care Medicine, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, 201318, People's Republic of China
| | - Liu Zhang
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.,Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Qing Yun Li
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China. .,Institute of Respiratory Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
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Impact of Altered Airway Pressure on Intracranial Pressure, Perfusion, and Oxygenation: A Narrative Review. Crit Care Med 2019; 47:254-263. [PMID: 30653472 DOI: 10.1097/ccm.0000000000003558] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES A narrative review of the pathophysiology linking altered airway pressure and intracranial pressure and cerebral oxygenation. DATA SOURCES Online search of PubMed and manual review of articles (laboratory and patient studies) of the altered airway pressure on intracranial pressure, cerebral perfusion, or cerebral oxygenation. STUDY SELECTION Randomized trials, observational and physiologic studies. DATA EXTRACTION Our group determined by consensus which resources would best inform this review. DATA SYNTHESIS In the normal brain, positive-pressure ventilation does not significantly alter intracranial pressure, cerebral oxygenation, or perfusion. In injured brains, the impact of airway pressure on intracranial pressure is variable and determined by several factors; a cerebral venous Starling resistor explains much of the variability. Negative-pressure ventilation can improve cerebral perfusion and oxygenation and reduce intracranial pressure in experimental models, but data are limited, and mechanisms and clinical benefit remain uncertain. CONCLUSIONS The effects of airway pressure and ventilation on cerebral perfusion and oxygenation are increasingly understood, especially in the setting of brain injury. In the face of competing mechanisms and priorities, multimodal monitoring and individualized titration will increasingly be required to optimize care.
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Yu J, Park JY, Kim DH, Koh GH, Kim S, Hwang JH, Oh TS, Kim YK. Effect of neck extension on ultrasonographic optic nerve sheath diameter as a surrogate for intracranial pressure in patients undergoing palatoplasty: A prospective observational study. J Plast Reconstr Aesthet Surg 2019; 73:369-375. [PMID: 31676124 DOI: 10.1016/j.bjps.2019.09.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/11/2019] [Accepted: 09/25/2019] [Indexed: 11/25/2022]
Abstract
Palatoplasty is performed with neck extension in patients with a cleft palate. The neck extension required for a better surgical view during palatoplasty can affect intracranial pressure. We evaluated the effect of neck extension on intracranial pressure by measuring the optic nerve sheath diameter using ultrasonography during palatoplasty. The optic nerve sheath diameter was measured in 30 patients at 10 min after anesthetic induction in the supine position (T1), at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4). Hemodynamic and respiratory variables such as systolic blood pressure, heart rate, end-tidal carbon dioxide partial pressure, and peak airway pressure were also measured at the same time points. In comparison with the optic nerve sheath diameter measured at 10 min after anesthetic induction in the supine position (T1), the mean optic nerve sheath diameters were significantly increased at 10 min after neck extension before preparing for a sterile field (T2), at the end of surgery with neck extension (T3), and at 10 min after the supine position (T4; 4.19 ± 0.26, 5.20 ± 0.29, 4.38 ± 0.36, and 4.35 ± 0.30 mm, respectively). However, hemodynamic and respiratory variables were not significantly different at all time points. We found that the optic nerve sheath diameter, an indicator of intracranial pressure, was increased during palatoplasty with neck extension, which suggests that the position may affect the intracranial pressure of patients with a cleft palate.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gi-Ho Koh
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Republic of Korea
| | - Sungwon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Suk Oh
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Le Guen M, Paternot A, Declerck A, Feliot E, Gayat E, Gaillard S, Fischler M. Impact of the modality of mechanical ventilation on bleeding during pituitary surgery: A single blinded randomized trial. Medicine (Baltimore) 2019; 98:e17254. [PMID: 31567997 PMCID: PMC6756699 DOI: 10.1097/md.0000000000017254] [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: 11/26/2022] Open
Abstract
BACKGROUND Bleeding modifies the surgeon's view of the field during transsphenoidal endoscopic pituitary surgery. Since ventilation can alter venous return, we compared the effect of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) on intraoperative bleeding. METHODS Eighty-six patients were randomized to VCV or PCV in this single blinded study; comparisons concerned 42 in the PCV group and 43 in the VCV group. RESULTS Intraoperative bleeding, the primary endpoint, did not differ between groups whether analysis focused on 7 levels of the score, from minimal bleeding to bleeding with significant change in the conduct of surgical procedure (P = .89) or on a stratification into 3 categories, mild, moderate, and major (P = .47). Median [interquartile range] peak airway pressure was lower in the PCV group (13.5 [12.5-15] vs 16.3 [14.4-19.1] cm H2O, P < .001) while mean airway pressures were similar (P = .08). Means ± SD of tidal volumes were lower in the VCV group when expressed as absolute values (470.6 ± 84 vs 434.7 ± 71.7 ml, P = .05) or as tidal volume/theoretical ideal weight ratio (6.7 [6.5-7] vs 7.2 [6.9-7.9], P < .001). The 2 groups were similar for postoperative complications and number of patients cured. CONCLUSION In conclusion, ventilation mode does not influence intraoperative bleeding during transsphenoidal pituitary surgery. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01891838; July 3, 2013.
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Affiliation(s)
- Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, 92150 Suresnes
- University Versailles Saint-Quentin en Yvelines, 78180 Montigny-Le-Bretonneux
| | - Alexis Paternot
- University Versailles Saint-Quentin en Yvelines, 78180 Montigny-Le-Bretonneux
- Department of Critical Care Medicine, Hôpital Ambroise Paré, 92100 Boulogne-Billancourt
| | - Agnes Declerck
- Department of Anesthesiology, Hôpital Foch, 92150 Suresnes
| | - Elodie Feliot
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis-Lariboisière, AP-HP, Paris
- INSERM UMR-S 942, Paris, France
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Hôpital Saint Louis-Lariboisière, AP-HP, Paris
- INSERM UMR-S 942, Paris, France
| | - Stephan Gaillard
- Department of Neurosurgery, Hôpital Foch, 92150 Suresnes, France
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, 92150 Suresnes
- University Versailles Saint-Quentin en Yvelines, 78180 Montigny-Le-Bretonneux
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You AH, Song Y, Kim DH, Suh J, Baek JW, Han DW. Effects of positive end-expiratory pressure on intraocular pressure and optic nerve sheath diameter in robot-assisted laparoscopic radical prostatectomy: A randomized, clinical trial. Medicine (Baltimore) 2019; 98:e15051. [PMID: 30946349 PMCID: PMC6455825 DOI: 10.1097/md.0000000000015051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND There has been no study of the effect of post end-expiratory pressure (PEEP) on intraocular or intracranial pressure during pneumoperitoneum with steep Trendelenburg positioning. We investigated the effects of 5 cmH2O of PEEP on intraocular pressure and optic nerve sheath diameter as a surrogate for intracranial pressure in robot-assisted laparoscopic radical prostatectomy. METHODS Fifty patients scheduled for robot-assisted laparoscopic radical prostatectomy were divided into a zero-PEEP (ZEEP) group and a 5 cmH2O of PEEP (PEEP) group. Intraocular pressure, optic nerve sheath diameter, and respiratory and hemodynamic parameters were measured before induction (T0), 10 minutes after induction of general anesthesia in the supine position before CO2 insufflation (T1), 5 minutes (T2), and 30 minutes (T3) after steep Trendelenburg positioning with pneumoperitoneum, after desufflation of pneumoperitoneum in the supine position (T4), and after 30 minutes in the recovery room postoperatively (T5). RESULTS There was no significant difference in intraocular pressure or optic nerve sheath diameter between the groups during the study. The partial pressure of arterial oxygen and dynamic lung compliance at T1, T2, T3, and T4 were significantly higher in the PEEP than in the ZEEP group. There was no difference in mean arterial pressure or heart rate between groups at any time. CONCLUSION Applying 5 cmH2O of PEEP did not increase intraocular pressure or optic nerve sheath diameter during pneumoperitoneum with steep Trendelenburg positioning in robot-assisted laparoscopic radical prostatectomy. These results suggest that low PEEP can be safely applied during surgery with pneumoperitoneum and steep Trendelenburg positioning in patients without preexisting eye disease and brain pathology.
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Affiliation(s)
- Ann Hee You
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital
| | - Young Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
| | - Jiwoo Suh
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Won Baek
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute
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Qin C, Olivencia-Yurvati AH, Williams AG, Eskildsen D, Mallet RT, Dasgupta PK. Inline flow sensor for ventriculoperitoneal shunts: Experimental evaluation in swine. Med Eng Phys 2019; 67:66-72. [PMID: 30922842 DOI: 10.1016/j.medengphy.2019.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/10/2019] [Accepted: 03/17/2019] [Indexed: 10/27/2022]
Abstract
Shunts are commonly employed to treat hydrocephalus, a severe central nervous disease caused by the buildup of cerebrospinal fluid in the brain. These shunts divert excessive cerebrospinal fluid from brain ventricles to other body cavities, thereby relieving the symptoms. However, these shunts are highly prone to failure due to obstruction from cellular debris, leading to cerebrospinal fluid accumulation in the brain and exacerbation of neurological symptoms. Therefore, there is a clinical need for a reliable, non-invasive method of monitoring shunt performance. Recently, a simple inline flow sensor was reported for monitoring ventriculoperitoneal shunting of cerebrospinal fluid in hydrocephalus treatment. The present work aimed to evaluate performance of the device in an animal model of hydrocephalus. Sensor-equipped shunt tubes were placed in anesthetized, juvenile swine. The flows reported by the sensor were compared with gravimetric flow measurements. Robust correlations (r ≈ 0.87-0.96) between the gravimetric and sensor-reported flows were obtained in 4 of the 6 experiments. The mean slope of the linear relationship of the gravimetrically determined vs. sensor flow rates was 0.98 ± 0.09 in the 6 experiments, indicating the sensor accurately reported shunt flows up to 35 ml/h. The sensor responded immediately to abrupt flow changes following cerebroventricular fluid injections. Minor hardware problems were identified and corrected. These experiments provide practical guidance for future preclinical testing of the device.
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Affiliation(s)
- Chuchu Qin
- Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, TX 76019-0065, United States
| | - Albert H Olivencia-Yurvati
- Department of Medical Education, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, United States; Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, United States
| | - Arthur G Williams
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, United States
| | - Dane Eskildsen
- Department of Medical Education, Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, United States
| | - Robert T Mallet
- Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, United States
| | - Purnendu K Dasgupta
- Department of Chemistry and Biochemistry, University of Texas at Arlington, Arlington, TX 76019-0065, United States.
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Bala R, Kumar R, Sharma J. A study to evaluate effect of PEEP and end-tidal carbon dioxide on optic nerve sheath diameter. Indian J Anaesth 2019; 63:537-543. [PMID: 31391616 PMCID: PMC6644203 DOI: 10.4103/ija.ija_861_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background and Aims: PEEP is commonly used to improve postoperative respiratory outcomes in surgical and ICU patients. It is thought to increase ICP by impending CSF outflow and cerebral venous drainage. Hyperventilation is used to decrease ICP in patients having intracranial hypertension. We investigated the effect of various levels of PEEP and EtCO2 on ONSD as an indirect predictor of ICP in patients undergoing surgery under GA. Methods: After induction, different levels of PEEP and EtCO2 were applied to 50 patients. Sonographic ONSD was measured 5 minutes after stabilization of each new setting. Haemodynamic parameters like pulse, SpO2, BP were also recorded. Quantitative variables were expressed as Mean ± SD and compared across between follow-ups using paired t-test. Qualitative variables were expressed in number and percentage. Results: Baseline ONSD was 0.44 ± 0.06 cm. It increased significantly to 0.45 ± 0.07 cm, 0.47 ± 0.07 cm and 0.49 ± 0.07 cm after applying PEEP of 8, 12 and 15 cm H2O PEEP, respectively. It significantly decreased to 0.42 ± 0.06 cm, 0.41 ± 0.06 cm and 0.40 ± 0.06 cm after hyperventilation, EtCO2 range 35–37, 32–34 and 29–31 mm Hg. Results were statistically significant but clinically not significant. Conclusion: We conclude that there are acute and dynamic alterations in ONSD in response to hyperventilation and presence of PEEP in anaesthetised patients. Ocular sonography may be used as a reliable indicator of acute variations in ICP.
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Affiliation(s)
- Renu Bala
- Department of Anaesthesiology and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Rajesh Kumar
- Department of Anaesthesiology and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Jyoti Sharma
- Department of Anaesthesiology and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Park J. Monitoring and Interpretation of Mechanical Ventilator Waveform in the Neuro-Intensive Care Unit. JOURNAL OF NEUROCRITICAL CARE 2018. [DOI: 10.18700/jnc.180069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Chen H, Zhou J, Lin YQ, Zhou JX, Yu RG. Intracranial pressure responsiveness to positive end-expiratory pressure in different respiratory mechanics: a preliminary experimental study in pigs. BMC Neurol 2018; 18:183. [PMID: 30396336 PMCID: PMC6217765 DOI: 10.1186/s12883-018-1191-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 10/28/2018] [Indexed: 12/13/2022] Open
Abstract
Background Respiratory mechanics affects the effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP). Respiratory mechanics of the lung and the chest wall was not differentiated in previous studies. In the present study, we investigated the influence of the following possible determinants of ICP responsiveness to PEEP: chest wall elastance (ECW), lung elastance (EL), and baseline ICP. Methods Eight healthy Bama miniature pigs were studied. The increase of EL was induced by instillation of hydrochloride, and the increase of ECW was induced by strapping the animals’ chest wall and abdomen. A balloon-tipped catheter was placed intracranially for inducing intracranial hypertension. Six experimental conditions were investigated in sequence: 1) Normal; 2) Stiff Chest Wall; 3) Lung Injury; 4) Lung Injury + Stiff Chest Wall; 5) Lung Injury + Stiff Chest Wall + Intracranial Hypertension and 6) Lung Injury + Intracranial Hypertension. PEEP was gradually increased in a 5 cm H2O interval from 5 to 25 cm H2O in each condition. Blood pressure, central venous pressure, ICP, airway pressure and esophageal pressure were measured. Results Hydrochloride instillation significantly increased EL in conditions with lung injury. ECW significantly increased in the conditions with chest wall and abdomen strapping (all p < 0.05). ICP significantly increased with increments of PEEP in all non-intracranial hypertension conditions (p < 0.001). The greatest cumulative increase in ICP was observed in the Stiff Chest Wall condition (6 [5.3, 6.8] mm Hg), while the lowest cumulative increase in ICP was observed in the Lung Injury condition (2 [1.3, 3.8] mm Hg). ICP significantly decreased when PEEP was increased in the intracranial hypertension conditions (p < 0.001). There was no significant difference in cumulative ICP change between the two intracranial hypertension conditions (p = 0.924). Conclusions Different respiratory mechanics models can be established via hydrochloride induced lung injury and chest wall and abdominal strapping. The effect of PEEP on ICP is determined by respiratory mechanics in pigs with normal ICP. However, the responsiveness of ICP to PEEP is independent of respiratory mechanics when there is intracranial hypertension.
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Affiliation(s)
- Han Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China.
| | - Jing Zhou
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Yi-Qin Lin
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, No 134, Dongjie Street, Gulou District, Fuzhou, 350001, Fujian, China
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Feasibility of Protective Ventilation During Elective Supratentorial Neurosurgery: A Randomized, Crossover, Clinical Trial. J Neurosurg Anesthesiol 2018; 30:246-250. [PMID: 28671879 DOI: 10.1097/ana.0000000000000442] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Traditional ventilation approaches, providing high tidal volumes (Vt), produce excessive alveolar distention and lung injury. Protective ventilation, employing lower Vt and positive end-expiratory pressure (PEEP), is an attractive alternative also for neuroanesthesia, when prolonged mechanical ventilation is needed. Nevertheless, protective ventilation during intracranial surgery may exert dangerous effects on intracranial pressure (ICP). We tested the feasibility of a protective ventilation strategy in neurosurgery. MATERIALS AND METHODS Our monocentric, double-blind, 1:1 randomized, 2×2 crossover study aimed at studying the effect size and variability of ICP in patients undergoing elective supratentorial brain tumor removal and alternatively ventilated with Vt 9 mL/kg-PEEP 0 mm Hg and Vt 7 mL/kg-PEEP 5 mm Hg. Respiratory rate was adjusted to maintain comparable end-tidal carbon dioxide between ventilation modes. ICP was measured through a subdural catheter inserted before dural opening. RESULTS Forty patients were enrolled; 8 (15%) were excluded after enrollment. ICP did not differ between traditional and protective ventilation (11.28±5.37, 11 [7 to 14.5] vs. 11.90±5.86, 11 [8 to 15] mm Hg; P=0.541). End-tidal carbon dioxide (28.91±2.28, 29 [28 to 30] vs. 28.00±2.17, 28 [27 to 29] mm Hg; P<0.001). Peak airway pressure (17.25±1.97, 17 [16 to 18.5] vs. 15.81±2.87, 15.5 [14 to 17] mm Hg; P<0.001) and plateau airway pressure (16.06±2.30, 16 [14.5 to 17] vs. 14.19±2.82, 14 [12.5 to 16] mm Hg; P<0.001) were higher during protective ventilation. Blood pressure, heart rate, and body temperature did not differ between ventilation modes. Dural tension was "acceptable for surgery" in all cases. ICP differences between ventilation modes were not affected by ICP values under traditional ventilation (coefficient=0.067; 95% confidence interval, -0.278 to 0.144; P=0.523). CONCLUSIONS Protective ventilation is a feasible alternative to traditional ventilation during elective neurosurgery.
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Serena K, Piva JP, Andreolio C, Carvalho PRA, Rocha TSD. Accidental strangulation in children by the automatic closing of a car window. Rev Bras Ter Intensiva 2018; 30:112-115. [PMID: 29742212 PMCID: PMC5885238 DOI: 10.5935/0103-507x.20180017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/13/2017] [Indexed: 11/21/2022] Open
Abstract
Among the main causes of death in our country are car accidents, drowning and
accidental burns. Strangulation is a potentially fatal injury and an important
cause of homicide and suicide among adults and adolescents. In children, its
occurrence is usually accidental. However, in recent years, several cases of
accidental strangulation in children around the world have been reported. A
2-year-old male patient was strangled in a car window. The patient was admitted
to the pediatric intensive care unit with a Glasgow Coma Scale score of 8 and
presented with progressive worsening of respiratory dysfunction and torpor. The
patient also presented acute respiratory distress syndrome, acute pulmonary
edema and shock. He was managed with protective mechanical ventilation,
vasoactive drugs and antibiotic therapy. He was discharged from the intensive
care unit without neurological or pulmonary sequelae. After 12 days of
hospitalization, he was discharged from the hospital, and his state was very
good. The incidence of automobile window strangulation is rare but of high
morbidity and mortality due to the resulting choking mechanism. Fortunately,
newer cars have devices that stop the automatic closing of the windows if
resistance is encountered. However, considering the severity of complications
strangulated patients experience, the intensive neuro-ventilatory and
hemodynamic management of the pathologies involved is important to reduce
morbidity and mortality, as is the need to implement new campaigns for the
education of parents and caregivers of children, aiming to avoid easily
preventable accidents and to optimize safety mechanisms in cars with electric
windows.
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Affiliation(s)
- Kailene Serena
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Jefferson Pedro Piva
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Cinara Andreolio
- Unidade de Terapia Intensiva Pediátrica, Hospital das Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | - Tais Sica da Rocha
- Pediatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Corradi F, Robba C, Tavazzi G, Via G. Combined lung and brain ultrasonography for an individualized "brain-protective ventilation strategy" in neurocritical care patients with challenging ventilation needs. Crit Ultrasound J 2018; 10:24. [PMID: 30221312 PMCID: PMC6139291 DOI: 10.1186/s13089-018-0105-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 08/23/2018] [Indexed: 01/27/2023] Open
Abstract
When intracranial hypertension and severe lung damage coexist in the same clinical scenario, their management poses a difficult challenge, especially as concerns mechanical ventilation management. The needs of combined lung and brain protection from secondary damage may conflict, as ventilation strategies commonly used in patients with ARDS are potentially associated with an increased risk of intracranial hypertension. In particular, the use of positive end-expiratory pressure, recruitment maneuvers, prone positioning, and protective lung ventilation can have undesirable effects on cerebral physiology: they may positively or negatively affect intracranial pressure, based on the final repercussions on PaO2 and cerebral perfusion pressure (through changes in cardiac output, mean arterial pressure, venous return, PaO2 and PaCO2), also according to the baseline conditions of cerebral autoregulation. Lung ultrasound (LUS) and brain ultrasound (BUS, as a combination of optic nerve sheath diameter assessment and cerebrovascular Doppler ultrasound) have independently proven their potential in respectively monitoring lung aeration and brain physiology at the bedside. In this narrative review, we describe how the combined use of LUS and BUS on neurocritical patients with demanding mechanical ventilation needs can contribute to ventilation management, with the aim of a tailored "brain-protective ventilation strategy."
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Affiliation(s)
- Francesco Corradi
- Servizio di Anestesia e Rianimazione, Ente ospedaliero Ospedali Galliera, Genoa, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCSS S. Martino Hospital, Genoa, Italy.,Neurocritical Care Unit, Addenbrookes Hospital Cambridge, Cambridge, UK
| | - Guido Tavazzi
- Emergency Department, Anaesthesia and Intensive Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, Anaesthesia, Intensive Care and Pain Therapy Unit, University of Pavia, Pavia, Italy
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Via Tesserete, 48, Lugano, Switzerland.
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Chen H, Chen K, Xu JQ, Zhang YR, Yu RG, Zhou JX. Intracranial pressure responsiveness to positive end-expiratory pressure is influenced by chest wall elastance: a physiological study in patients with aneurysmal subarachnoid hemorrhage. BMC Neurol 2018; 18:124. [PMID: 30143022 PMCID: PMC6108121 DOI: 10.1186/s12883-018-1132-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/20/2018] [Indexed: 12/18/2022] Open
Abstract
Background Respiratory system elastance (ERS) is an important determinant of the responsiveness of intracranial pressure (ICP) to positive end-expiratory pressure (PEEP). However, lung elastance (EL) and chest wall elastance (ECW) were not differentiated in previous studies. We tested the hypothesis that patients with high ECW or a high ECW/ERS ratio have greater ICP responsiveness to PEEP. Methods An esophageal balloon catheter was placed to measure esophageal pressure. PEEP was increased from 5 to 15 cmH2O. Airway pressure and esophageal pressure were measured and EL, ECW and ERS were calculated at the two PEEP levels. Patients were classified into either an ICP responder group or a non-responder group based on whether the change of ICP after PEEP adjustment was greater than or less than the median of the overall study population. Results The magnitude of the increase in esophageal pressure (median [interquartile range]) at end-expiratory occlusion was significantly increased in the responder group compared with that in the non-responder group (4.1 [2.7–4.1] versus 2.7 [0.0–2.7] cmH2O, p = 0.033) after PEEP adjustment. ECW and the ECW/ERS ratio were significantly higher in ICP responders than in non-responders at both low PEEP (p = 0.021 and 0.017) and high PEEP (p = 0.011 and 0.025) levels. No significant differences in ERS and EL were noted between the two groups at both PEEP levels. Conclusions Patients with greater ICP responsiveness to increased PEEP exhibit higher ECW and a higher ECW/ERS ratio, suggesting the importance of ECW monitoring. Electronic supplementary material The online version of this article (10.1186/s12883-018-1132-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing, China.,Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Kai Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Jing-Qing Xu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Ying-Rui Zhang
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing, China.
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Cavallo C, Safavi-Abbasi S, Kalani MYS, Gandhi S, Sun H, Oppenlander ME, Zabramski JM, Nakaji P, Lawton MT, Spetzler RF. Pulmonary Complications After Spontaneous Aneurysmal Subarachnoid Hemorrhage: Experience from Barrow Neurological Institute. World Neurosurg 2018; 119:e366-e373. [PMID: 30075258 DOI: 10.1016/j.wneu.2018.07.166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Because the clinical course of spontaneous aneurysmal subarachnoid hemorrhage (aSAH) can be compromised by pulmonary complications, we sought to review posttreatment outcomes in aSAH patients with and without pulmonary complications. METHODS Patient demographic, clinical, and outcome data (March 2003-January 2007) were analyzed retrospectively. Patients underwent microsurgical or endovascular treatment for aSAH; pulmonary complications were reported. Outcomes were assessed using the Glasgow Outcome Scale (GOS) scores at the 1-year, 3-year, and 6-year follow-up visits. RESULTS The cohort comprised 471 patients (mean age, 53.7 ± 12.4 years; men, 332/471 [70%]). The mean Glasgow Coma Scale (GCS) score at presentation was 11.9 ± 3.0. Of 471 patients, 47% (n = 223) presented with a Hunt and Hess score of ≥3 and 76% (n = 357) with a Fisher grade of 3. Treatment was clipping for 69% (279/407) and coiling for 31% (128/407) of patients. Pulmonary complications occurred in 210 of 471 (45%) patients. Nearly one-half of patients were discharged to home (215/471, 46%), and more than one-half had a good outcome defined as a GOS score of 5 at their 1-year (226/403, 56%), 3-year (217/397, 55%), and 6-year (203/380, 53%) follow-up visits. Logistic regression showed age and GCS scores as outcome predictors at all time points, whereas pulmonary complications predicted poor outcome only at the 1-year follow-up visit. CONCLUSIONS Pulmonary problems represent the most common nonneurologic medical complications after aSAH. Despite advances in critical care, pulmonary complications represented predictors of short-term poor outcome only at the 1-year follow-up visit, whereas the medical history of the patient became more relevant for prognosis in long-term follow-up.
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Affiliation(s)
- Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sam Safavi-Abbasi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Hai Sun
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark E Oppenlander
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph M Zabramski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Khandelwal A, Kapoor I, Mahajan C, Prabhakar H. Effect of Positive End-Expiratory Pressure on Optic Nerve Sheath Diameter in Pediatric Patients with Traumatic Brain Injury. J Pediatr Neurosci 2018; 13:165-169. [PMID: 30090129 PMCID: PMC6057201 DOI: 10.4103/jpn.jpn_112_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: The peak incidence of traumatic brain injury (TBI) has been reported in children and young adults. Intracranial pressure (ICP) as an important component can be measured with invasive technique, whereas noninvasive measurement of optic nerve sheath diameter (ONSD) is increasingly becoming popular. Positive end-expiratory pressure (PEEP) has been found to affect ICP. We aimed to compare the effect of different values of PEEP on ONSD and to obtain the correlation with ICP measurement. Setting and Design: Neurointensive Care Unit, Trauma Center, AIIMS, New Delhi. Materials and Methods: Pediatric patients with TBI, of either gender, between 1 and 18 years of age in whom ICP was measured using intraparenchymal Codman catheter admitted in neurointensive care unit were enrolled. For this crossover study, the sequence of PEEP (0 or 3 or 5 cm H2O) was randomized and ONSD was measured. The mean of three ONSD values was taken as final value. Statistical Method: The ONSD, ICP, peak airway pressure, and hemodynamic parameters at various stages were compared using two-way repeated measures analysis of variance with Bonferroni correction. A P value of <0.05 was considered to be significant. Results: Ten patients (seven males, three females) participated in the study. There was no significant increase in ONSD values when PEEP was increased from 0 to 3 cm H2O. However, increase in PEEP values from 3 to 5 cm H2O showed significantly increased ONSD values. Conclusion: PEEP up to 3 cm H2O can be safely applied in pediatric patients following TBI. Further increment of PEEP might accentuate the ICP values.
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Affiliation(s)
- Ankur Khandelwal
- Department of Neuroanesthesiology and Critical Care, Neuroscience Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Indu Kapoor
- Department of Neuroanesthesiology and Critical Care, Neuroscience Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Charu Mahajan
- Department of Neuroanesthesiology and Critical Care, Neuroscience Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanesthesiology and Critical Care, Neuroscience Center, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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The Effect of Positive End-Expiratory Pressure on Intracranial Pressure and Cerebral Hemodynamics. Neurocrit Care 2017; 26:174-181. [PMID: 27848125 DOI: 10.1007/s12028-016-0328-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lung protective ventilation has not been evaluated in patients with brain injury. It is unclear whether applying positive end-expiratory pressure (PEEP) adversely affects intracranial pressure (ICP) and cerebral perfusion pressure (CPP). We aimed to evaluate the effect of PEEP on ICP and CPP in a large population of patients with acute brain injury and varying categories of acute lung injury, defined by PaO2/FiO2. METHOD Retrospective data were collected from 341 patients with severe acute brain injury admitted to the ICU between 2008 and 2015. These patients experienced a total of 28,644 paired PEEP and ICP observations. Demographic, hemodynamic, physiologic, and ventilator data at the time of the paired PEEP and ICP observations were recorded. RESULTS In the adjusted analysis, a statistically significant relationship between PEEP and ICP and PEEP and CPP was found only among observations occurring during periods of severe lung injury. For every centimeter H2O increase in PEEP, there was a 0.31 mmHg increase in ICP (p = 0.04; 95 % CI [0.07, 0.54]) and a 0.85 mmHg decrease in CPP (p = 0.02; 95 % CI [-1.48, -0.22]). CONCLUSION Our results suggest that PEEP can be applied safely in patients with acute brain injury as it does not have a clinically significant effect on ICP or CPP. Further prospective studies are required to assess the safety of applying a lung protective ventilation strategy in brain-injured patients with lung injury.
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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Jeong JH. Brain and Lung: Lung Injury in Patients with Brain Injury. JOURNAL OF NEUROCRITICAL CARE 2017. [DOI: 10.18700/jnc.170009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Flexman AM, Gooderham PA, Griesdale DE, Argue R, Toyota B. Effects of an alveolar recruitment maneuver on subdural pressure, brain swelling, and mean arterial pressure in patients undergoing supratentorial tumour resection: a randomized crossover study. Can J Anaesth 2017; 64:626-633. [PMID: 28342045 DOI: 10.1007/s12630-017-0863-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/11/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Although recruitment maneuvers have been advocated as part of a lung protective ventilation strategy, their effects on cerebral physiology during elective neurosurgery are unknown. Our objectives were to determine the effects of an alveolar recruitment maneuver on subdural pressure (SDP), brain relaxation score (BRS), and cerebral perfusion pressure among patients undergoing supratentorial tumour resection. METHODS In this prospective crossover study, patients scheduled for resection of a supratentorial brain tumour were randomized to undergo either a recruitment maneuver (30 cm of water for 30 sec) or a "sham" maneuver (5 cm of water for 30 sec), followed by the alternative intervention after a 90-sec equilibration period. Subdural pressure was measured through a dural perforation following opening of the cranium. Subdural pressure and mean arterial pressure (MAP) were recorded continuously. The blinded neurosurgeon provided a BRS at baseline and at the end of each intervention. During each treatment, the changes in SDP, BRS, and MAP were compared. RESULTS Twenty-one patients underwent the study procedure. The increase in SDP was higher during the recruitment maneuver than during the sham maneuver (difference, 3.9 mmHg; 95% confidence interval [CI], 2.2 to 5.6; P < 0.001). Mean arterial pressure decreased further in the recruitment maneuver than in the sham maneuver (difference, -9.0 mmHg; 95% CI, -12.5 to -5.6; P < 0.001). Cerebral perfusion pressure decreased 14 mmHg (95% CI, 4 to 24) during the recruitment maneuver. The BRS did not change with either maneuver. CONCLUSION Our results suggest that recruitment maneuvers increase subdural pressure and reduce cerebral perfusion pressure, although the clinical importance of these findings is thus far unknown. This trial was registered with ClinicalTrials.gov, NCT02093117.
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Affiliation(s)
- Alana M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Room 2449 JPP 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Peter A Gooderham
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Room 2449 JPP 899 West 12th Avenue, Vancouver, BC, V5Z 1M9, Canada
| | - Ruth Argue
- Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Wellcome Trust HRB Clinical Research Facility, St. James's Hospital, H&H Building, Level 2, Dublin 8, Ireland
| | - Brian Toyota
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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Affiliation(s)
- Dong Woo Han
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Although urgent surgical hematoma evacuation is necessary for most patients with subdural hematoma (SDH), well-orchestrated, evidenced-based, multidisciplinary, postoperative critical care is essential to achieve the best possible outcome. Acute SDH complicates approximately 11% of mild to moderate traumatic brain injuries (TBIs) that require hospitalization, and approximately 20% of severe TBIs. Acute SDH usually is related to a clear traumatic event, but in some cases can occur spontaneously. Management of SDH in the setting of TBI typically conforms to the Advanced Trauma Life Support protocol with airway taking priority, and management breathing and circulation occurring in parallel rather than sequence.
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Affiliation(s)
- Fawaz Al-Mufti
- Endovascular Surgical Neuroradiology Program, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, 2799 W Grand Boulevard, Detroit, MI 48202, USA.
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Comparison of the Effects of Different Positive End-Expiratory Pressure Levels on Cerebral Oxygen Saturation With Near Infrared Spectroscopy During Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2017; 27:30-35. [DOI: 10.1097/sle.0000000000000372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chin JH, Kim WJ, Lee J, Han YA, Lim J, Hwang JH, Cho SS, Kim YK. Effect of Positive End-Expiratory Pressure on the Sonographic Optic Nerve Sheath Diameter as a Surrogate for Intracranial Pressure during Robot-Assisted Laparoscopic Prostatectomy: A Randomized Controlled Trial. PLoS One 2017; 12:e0170369. [PMID: 28107408 PMCID: PMC5249217 DOI: 10.1371/journal.pone.0170369] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 01/02/2017] [Indexed: 12/05/2022] Open
Abstract
Background Positive end-expiratory pressure (PEEP) can increase intracranial pressure. Pneumoperitoneum and the Trendelenburg position are associated with an increased intracranial pressure. We investigated whether PEEP ventilation could additionally influence the sonographic optic nerve sheath diameter as a surrogate for intracranial pressure during pneumoperitoneum combined with the Trendelenburg position in patients undergoing robot-assisted laparoscopic prostatectomy. Methods After anesthetic induction, 38 patients were randomly allocated to a low tidal volume ventilation (8 ml/kg) without PEEP group (zero end-expiratory pressure [ZEEP] group, n = 19) or low tidal volume ventilation with 8 cmH2O PEEP group (PEEP group, n = 19). The sonographic optic nerve sheath diameter was measured prior to skin incision, 5 min and 30 min after pneumoperitoneum and the Trendelenburg position, and at the end of surgery. The study endpoint was the difference in the sonographic optic nerve sheath diameter 5 min after pneumoperitoneum and the Trendelenburg position between the ZEEP and PEEP groups. Results Optic nerve sheath diameters 5 min after pneumoperitoneum and the Trendelenburg position did not significantly differ between the groups [least square mean (95% confidence interval); 4.8 (4.6–4.9) mm vs 4.8 (4.7–5.0) mm, P = 0.618]. Optic nerve sheath diameters 30 min after pneumoperitoneum and the Trendelenburg position also did not differ between the groups [least square mean (95% confidence interval); 4.5 (4.3–4.6) mm vs 4.5 (4.4–4.6) mm, P = 0.733]. Conclusions An 8 cmH2O PEEP application under low tidal volume ventilation does not induce an increase in the optic nerve sheath diameter during pneumoperitoneum combined with the steep Trendelenburg position, suggesting that there might be no detrimental effects of PEEP on the intracranial pressure during robot-assisted laparoscopic prostatectomy. Trial Registration ClinicalTrial.gov NCT02516566
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Affiliation(s)
- Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wook-Jong Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joonho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun A. Han
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinwook Lim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Sik Cho
- Department of Occupational and Environmental Medicine, Konkuk University Chungju Hospital, Chungju, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- * E-mail:
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