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Boussen S, Benard-Tertrais M, Ogéa M, Malet A, Simeone P, Antonini F, Bruder N, Velly L. Heart rate complexity helps mortality prediction in the intensive care unit: A pilot study using artificial intelligence. Comput Biol Med 2024; 169:107934. [PMID: 38183707 DOI: 10.1016/j.compbiomed.2024.107934] [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: 05/13/2023] [Revised: 12/10/2023] [Accepted: 01/01/2024] [Indexed: 01/08/2024]
Abstract
BACKGROUND In intensive care units (ICUs), accurate mortality prediction is crucial for effective patient management and resource allocation. The Simplified Acute Physiology Score II (SAPS-2), though commonly used, relies heavily on comprehensive clinical data and blood samples. This study sought to develop an artificial intelligence (AI) model utilizing key hemodynamic parameters to predict ICU mortality within the first 24 h and assess its performance relative to SAPS-2. METHODS We conducted an analysis of select hemodynamic parameters and the structure of heart rate curves to identify potential predictors of ICU mortality. A machine-learning model was subsequently trained and validated on distinct patient cohorts. The AI algorithm's performance was then compared to the SAPS-2, focusing on classification accuracy, calibration, and generalizability. MEASUREMENTS AND MAIN RESULTS The study included 1298 ICU admissions from March 27th, 2015, to March 27th, 2017. An additional cohort from 2022 to 2023 comprised 590 patients, resulting in a total dataset of 1888 patients. The observed mortality rate stood at 24.0%. Key determinants of mortality were the Glasgow Coma Scale score, heart rate complexity, patient age, duration of diastolic blood pressure below 50 mmHg, heart rate variability, and specific mean and systolic blood pressure thresholds. The AI model, informed by these determinants, exhibited a performance profile in predicting mortality that was comparable, if not superior, to the SAPS-2. CONCLUSIONS The AI model, which integrates heart rate and blood pressure curve analyses with basic clinical parameters, provides a methodological approach to predict in-hospital mortality in ICU patients. This model offers an alternative to existing tools that depend on extensive clinical data and laboratory inputs. Its potential integration into ICU monitoring systems may facilitate more streamlined mortality prediction processes.
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Affiliation(s)
- Salah Boussen
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France; Laboratoire de Biomécanique Appliquée-Université Gustave-Eiffel, Aix-Marseille Université, UMR T24, 51 boulevard Pierre Dramard, 13015, Marseille, France.
| | - Manuela Benard-Tertrais
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Mathilde Ogéa
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Arthur Malet
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Pierre Simeone
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France; Aix Marseille University, CNRS, Inst Neurosci Timone, UMR7289, Marseille, France
| | - François Antonini
- Intensive Care and Anesthesiology Department, Hôpital Nord Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Nicolas Bruder
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Lionel Velly
- Intensive Care and Anesthesiology Department, La Timone Teaching Hospital, Aix-Marseille Université Assistance Publique Hôpitaux de Marseille, Marseille, France; Aix Marseille University, CNRS, Inst Neurosci Timone, UMR7289, Marseille, France
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Morris DC, Zhang ZG, Jaehne AK, Zhang J, Rivers EP. CLINICAL, MOLECULAR, AND EXOSOMAL MECHANISMS OF CARDIAC AND BRAIN DYSFUNCTION IN SEPSIS. Shock 2023; 59:173-179. [PMID: 36731014 DOI: 10.1097/shk.0000000000002015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Sepsis is a complex disease resulting from a dysregulated inflammatory response to an infection. Initiation of sepsis occurs from a localized infection that disseminates to the bloodstream placing all organ systems at risk. Septic shock is classically observed to manifest itself as systemic hypotension with hyporesponsiveness to vasopressor agents. Myocardial dysfunction occurs resulting in an inability to perfuse major organ systems throughout the body. Most importantly, the brain is hypoperfused creating an ischemic and inflammatory state resulting in the clinical observation of acute mental status changes and cognitive dysfunction commonly known as sepsis-associated encephalopathy. This short review describes the inflammatory molecular mechanisms of myocardial dysfunction, discusses the evidence of the dual roles of the microglia resulting in blood-brain barrier disruption, and suggests that septic-derived exosomes, endosome-derived lipid bilayer spheroids released from living cells, influence cardiac and neurological cellular function.
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Affiliation(s)
- Daniel C Morris
- Department of Emergency Medicine, Henry Ford Health, Detroit, Michigan
| | - Zheng Gang Zhang
- Department of Neurological Research, Henry Ford Health, Detroit, Michigan
| | - Anja K Jaehne
- Department of Emergency Medicine, Henry Ford Health, Detroit, Michigan
| | - Jing Zhang
- Department of Neurological Research, Henry Ford Health, Detroit, Michigan
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Martin S, Du Pont-Thibodeau G, Seely AJE, Emeriaud G, Herry CL, Recher M, Lacroix J, Ducharme-Crevier L. Heart Rate Variability in Children with Moderate and Severe Traumatic Brain Injury: A Prospective Observational Study. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1759877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AbstractThe aim of this study was to assess the feasibility of continuous monitoring of heart rate variability (HRV) in children with traumatic brain injury (TBI) hospitalized in a pediatric intensive care unit (PICU) and collect preliminary data on the association between HRV, neurological outcome, and complications. This is a prospective observational cohort study in a tertiary academic PICU. Children admitted to the PICU ≤24 hours after moderate or severe TBI were included in the study. Children suspected of being brain dead at PICU entry or with a pacemaker were excluded. Children underwent continuous monitoring of electrocardiographic (ECG) waveforms over 7 days post-TBI. HRV analysis was performed retrospectively, using a standardized, validated HRV analysis software (CIMVA). The occurrence of medical complications (“event”: intracranial hypertension, cerebral hypoperfusion, seizure, and cardiac arrest) was prospectively documented. Outcome of children 6 months post-TBI was assessed using the Glasgow Outcome Scale – Extended Pediatric (GOS-E Peds). Fifteen patients were included over a 20-month period. Thirteen patients had ECG recordings available and 4 had >20% of missing ECG data. When ECG was available, HRV calculation was feasible (average 88%; range 70–97%). Significant decrease in overall HRV coefficient of variation and Poincaré SD2 (p < 0.05) at 6 hours post–PICU admission was associated with an unfavorable outcome (defined as GOS-E Peds ≥ 3, or a deterioration of ≥2 points over baseline score). Several HRV metrics exhibited significant and nonsignificant variation in HRV during event. This study demonstrates that it is feasible to monitor HRV in the PICU provided ECG data are available; however, missing ECG data are not uncommon. These preliminary data suggest that altered HRV is associated with unfavorable neurological outcome and in-hospital medical complications. Larger prospective studies are needed to confirm these findings and to explore if HRV offers reliable and clinically useful prediction data that may help clinical decision making.
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Affiliation(s)
- Sophie Martin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Geneviève Du Pont-Thibodeau
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Andrew J. E. Seely
- Thoracic Surgery & Critical Care Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Guillaume Emeriaud
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Morgan Recher
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Laurence Ducharme-Crevier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
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Leveraging Continuous Vital Sign Measurements for Real-Time Assessment of Autonomic Nervous System Dysfunction After Brain Injury: A Narrative Review of Current and Future Applications. Neurocrit Care 2022; 37:206-219. [PMID: 35411542 DOI: 10.1007/s12028-022-01491-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 03/14/2022] [Indexed: 02/03/2023]
Abstract
Subtle and profound changes in autonomic nervous system (ANS) function affecting sympathetic and parasympathetic homeostasis occur as a result of critical illness. Changes in ANS function are particularly salient in neurocritical illness, when direct structural and functional perturbations to autonomic network pathways occur and may herald impending clinical deterioration or intervenable evolving mechanisms of secondary injury. Sympathetic and parasympathetic balance can be measured quantitatively at the bedside using multiple methods, most readily by extracting data from electrocardiographic or photoplethysmography waveforms. Work from our group and others has demonstrated that data-analytic techniques can identify quantitative physiologic changes that precede clinical detection of meaningful events, and therefore may provide an important window for time-sensitive therapies. Here, we review data-analytic approaches to measuring ANS dysfunction from routine bedside physiologic data streams and integrating this data into multimodal machine learning-based model development to better understand phenotypical expression of pathophysiologic mechanisms and perhaps even serve as early detection signals. Attention will be given to examples from our work in acute traumatic brain injury on detection and monitoring of paroxysmal sympathetic hyperactivity and prediction of neurologic deterioration, and in large hemispheric infarction on prediction of malignant cerebral edema. We also discuss future clinical applications and data-analytic challenges and future directions.
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Pearson R, Sheridan CA, Kang K, Brown A, Baham M, Asarnow R, Giza CC, Choe MC. Post-Concussive Orthostatic Tachycardia is Distinct from Postural Orthostatic Tachycardia Syndrome (POTS) in Children and Adolescents. Child Neurol Open 2022; 9:2329048X221082753. [PMID: 35647216 PMCID: PMC9136088 DOI: 10.1177/2329048x221082753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/14/2022] [Accepted: 02/03/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Orthostatic tachycardia (OT) affects some patients after
concussion/mild traumatic brain injury (mTBI). In this study, we sought to
identify the factors associated with increased risk for OT in patients with
mTBI. Methods: We conducted a retrospective review of 268 patients
(8-25 years) with mTBI/concussion to determine the prevalence of OT, defined as
orthostatic heart rate change ≥40 bpm for those ≤19 years of age and ≥30 bpm on
active standing test for those >19 years of age. Results: Among
the study population, 7% (n = 19) exhibited post-concussive OT. The only
significant difference between OT and non-OT groups was that history of prior
concussion was more prevalent in the OT group. Conclusion: A
substantial subset (7%) of concussion clinic patients exhibit OT. While POTS
literature describes female and adolescent predominance, post-concussive OT had
similar prevalence across age and gender groups in this study, suggesting that
it may be distinct from POTS.
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Affiliation(s)
- Rachel Pearson
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Division of Pediatric Neurology, UC-Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
- Children’s Hospital Orange County, Orange, California, USA
| | - Christopher A. Sheridan
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kaylee Kang
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
| | - Anne Brown
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
| | - Michael Baham
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- UC-Irvine School of Medicine, Irvine, CA, USA
| | - Robert Asarnow
- Psychiatry and Biobehavioral Science, University of California-Los Angeles, Los Angeles, CA, USA
| | - Christopher C. Giza
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Division of Pediatric Neurology, UC-Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Meeryo C. Choe
- UC-Los Angeles Steve Tisch BrainSPORT Program, UCLA Easton Clinic for Brain Health, Los Angeles, CA, USA
- Division of Pediatric Neurology, UC-Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, Los Angeles, CA, USA
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Fedriga M, Czigler A, Nasr N, Zeiler FA, Park S, Donnelly J, Papaioannou V, Frisvold SK, Wolf S, Rasulo F, Sykora M, Smielewski P, Czosnyka M. Autonomic Nervous System Activity during Refractory Rise in Intracranial Pressure. J Neurotrauma 2021; 38:1662-1669. [PMID: 33280491 PMCID: PMC8336253 DOI: 10.1089/neu.2020.7091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Refractory intracranial hypertension (RIH) is a dramatic increase in intracranial pressure (ICP) that cannot be controlled by treatment. Recent reports suggest that the autonomic nervous system (ANS) activity may be altered during changes in ICP. Our study aimed to assess ANS activity during RIH and the causal relationship between rising in ICP and autonomic activity. We reviewed retrospectively 24 multicenter (Cambridge, Tromso, Berlin) patients in whom RIH developed as a pre-terminal event after acute brain injury (ABI). They were monitored with ICP, arterial blood pressure (ABP), and electrocardiography (ECG) using ICM+ software. Parameters reflecting autonomic activity were computed in time and frequency domain through the measurement of heart rate variability (HRV) and baroreflex sensitivity (BRS). Our results demonstrated that a rise in ICP was associated to a significant rise in HRV and BRS with a higher significance level in the high-frequency HRV (p < 0.001). This increase was followed by a significant decrease in HRV and BRS above the upper-breakpoint of ICP where ICP pulse-amplitude starts to decrease whereas the mean ICP continues to rise. Temporality measured with a Granger test suggests a causal relationship from ICP to ANS. The above results suggest that a rise in ICP interacts with ANS activity, mainly interfacing with the parasympathetic-system. The ANS seems to react to the rise in ICP with a response possibly focused on maintaining the cerebrovascular homeostasis. This happens until the critical threshold of ICP is reached above which the ANS variables collapse, probably because of low perfusion of the brain and the central autonomic network.
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Affiliation(s)
- Marta Fedriga
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Andras Czigler
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs, Pecs, Hungary
| | - Nathalie Nasr
- Unitè de Neurologie Vasculaire, CHU de Toulouse, Universitè de Toulouse, Toulouse, France
| | - Frederick. A. Zeiler
- Department of Surgery, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Soojin Park
- Department of Neurology, Division of Hospitalist and Critical Care Neurology, Columbia University, New York, New York, USA
| | - Joseph Donnelly
- Department of Anaesthesiology, University of Auckland, Aukland, New Zealand
| | - Vasilios Papaioannou
- University Hospital of Alexandroupolis, Intensive Care Unit, Democritus University of Thrace, Alexandroupolis, Greece
| | - Shirin K Frisvold
- Department of Intensive Care, University Hospital of North Norway, UiT The Arctic University of Norway, Tromso, Norway
| | - Stephan Wolf
- Department of Neurosurgery, Charite Hospital, Berlin, Germany
| | - Frank Rasulo
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Marek Sykora
- Department of Neurology, St. John's Hospital Vienna, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Smielewski
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
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Heart Rate Variability Biofeedback Improves Emotional and Physical Health and Performance: A Systematic Review and Meta Analysis. Appl Psychophysiol Biofeedback 2021; 45:109-129. [PMID: 32385728 DOI: 10.1007/s10484-020-09466-z] [Citation(s) in RCA: 159] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We performed a systematic and meta analytic review of heart rate variability biofeedback (HRVB) for various symptoms and human functioning. We analyzed all problems addressed by HRVB and all outcome measures in all studies, whether or not relevant to the studied population, among randomly controlled studies. Targets included various biological and psychological problems and issues with athletic, cognitive, and artistic performance. Our initial review yielded 1868 papers, from which 58 met inclusion criteria. A significant small to moderate effect size was found favoring HRVB, which does not differ from that of other effective treatments. With a small number of studies for each, HRVB has the largest effect sizes for anxiety, depression, anger and athletic/artistic performance and the smallest effect sizes on PTSD, sleep and quality of life. We found no significant differences for number of treatment sessions or weeks between pretest and post-test, whether the outcome measure was targeted to the population, or year of publication. Effect sizes are larger in comparison to inactive than active control conditions although significant for both. HRVB improves symptoms and functioning in many areas, both in the normal and pathological ranges. It appears useful as a complementary treatment. Further research is needed to confirm its efficacy for particular applications.
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The autonomic nervous system in septic shock and its role as a future therapeutic target: a narrative review. Ann Intensive Care 2021; 11:80. [PMID: 33999297 PMCID: PMC8128952 DOI: 10.1186/s13613-021-00869-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/05/2021] [Indexed: 02/06/2023] Open
Abstract
The autonomic nervous system (ANS) regulates the cardiovascular system. A growing body of experimental and clinical evidence confirms significant dysfunction of this regulation during sepsis and septic shock. Clinical guidelines do not currently include any evaluation of ANS function during the resuscitation phase of septic shock despite the fact that the severity and persistence of ANS dysfunction are correlated with worse clinical outcomes. In the critical care setting, the clinical use of ANS-related hemodynamic indices is currently limited to preliminary investigations trying to predict and anticipate imminent clinical deterioration. In this review, we discuss the evidence supporting the concept that, in septic shock, restoration of ANS-mediated control of the cardiovascular system or alleviation of the clinical consequences induced by its dysfunction (e.g., excessive tachycardia, etc.), may be an important therapeutic goal, in combination with traditional resuscitation targets. Recent studies, which have used standard and advanced monitoring methods and mathematical models to investigate the ANS-mediated mechanisms of physiological regulation, have shown the feasibility and importance of monitoring ANS hemodynamic indices at the bedside, based on the acquisition of simple signals, such as heart rate and arterial blood pressure fluctuations. During the early phase of septic shock, experimental and/or clinical studies have shown the efficacy of negative-chronotropic agents (i.e., beta-blockers or ivabradine) in controlling persistent tachycardia despite adequate resuscitation. Central α-2 agonists have been shown to prevent peripheral adrenergic receptor desensitization by reducing catecholamine exposure. Whether these new therapeutic approaches can safely improve clinical outcomes remains to be confirmed in larger clinical trials. New technological solutions are now available to non-invasively modulate ANS outflow, such as transcutaneous vagal stimulation, with initial pre-clinical studies showing promising results and paving the way for ANS modulation to be considered as a new potential therapeutic target in patients with septic shock.
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Bersani I, Piersigilli F, Gazzolo D, Campi F, Savarese I, Dotta A, Tamborrino PP, Auriti C, Di Mambro C. Heart rate variability as possible marker of brain damage in neonates with hypoxic ischemic encephalopathy: a systematic review. Eur J Pediatr 2021; 180:1335-1345. [PMID: 33245400 PMCID: PMC7691422 DOI: 10.1007/s00431-020-03882-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/18/2020] [Accepted: 11/18/2020] [Indexed: 12/20/2022]
Abstract
Heart rate variability (HRV) is currently considered the most valuable non-invasive test to investigate the autonomic nervous system function, based on the fact that fast fluctuations might specifically reflect changes of sympathetic and vagal activity. An association between abnormal values of HRV and brain impairment has been reported in the perinatal period, although data are still fragmentary. Considering such association, HRV has been suggested as a possible marker of brain damage also in case of hypoxic-ischemic encephalopathy following perinatal asphyxia. The aim of the present manuscript was to review systematically the current knowledge about the use of HRV as marker of cerebral injury in neonates suffering from hypoxic-ischemic encephalopathy. Findings reported in this paper were based on qualitative analysis of the reviewed data. Conclusion: A growing body of research supports the use of HRV as non-invasive, bedside tool for the monitoring of hypoxic-ischemic encephalopathy. The currently available data about the role of HRV as prognostic tool in case of hypoxic ischemic encephalopathy are promising but require further validation by future studies. What is Known: • Heart rate variability (HRV) is a non-invasive monitoring technique to assess the autonomic nervous system activity. • A correlation between abnormal HRV and cerebral injury has been reported in the perinatal period, and HRV has been suggested as possible marker of brain damage in case of hypoxic-ischemic encephalopathy. What is New: • HRV might provide precocious information about the entity of brain injury in asphyxiated neonates and be of help to design early, specific, and personalized treatments according to severity. • Further investigations are required to confirm these preliminary data.
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Affiliation(s)
- Iliana Bersani
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Fiammetta Piersigilli
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Bruxelles, Belgium
| | - Diego Gazzolo
- Neonatal Intensive Care Unit, G. d’Annunzio University, Chieti, Italy
| | - Francesca Campi
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Immacolata Savarese
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Andrea Dotta
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Pietro Paolo Tamborrino
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Cinzia Auriti
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Corrado Di Mambro
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Complex Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
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Lee H, Jeon SB, Lee KS. Continuous heart rate variability and electroencephalography monitoring in severe acute brain injury: a preliminary study. Acute Crit Care 2021; 36:151-161. [PMID: 33730778 PMCID: PMC8182164 DOI: 10.4266/acc.2020.00703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background Decreases in heart rate variability have been shown to be associated with poor outcomes in severe acute brain injury. However, it is unknown whether the changes in heart rate variability precede neurological deterioration in such patients. We explored the changes in heart rate variability measured by electrocardiography in patients who had neurological deterioration following severe acute brain injury, and examined the relationship between heart rate variability and electroencephalography parameters. Methods Retrospective analysis of 25 patients who manifested neurological deterioration after severe acute brain injury and underwent simultaneous electroencephalography plus electrocardiography monitoring. Results Eighteen electroencephalography channels and one simultaneously recorded electrocardiography channel were segmented into epochs of 120-second duration and processed to compute 10 heart rate variability parameters and three quantitative electroencephalography parameters. Raw electroencephalography of the epochs was also assessed by standardized visual interpretation and categorized based on their background abnormalities and ictalinterictal continuum patterns. The heart rate variability and electroencephalography parameters showed consistent changes in the 2-day period before neurological deterioration commenced. Remarkably, the suppression ratio and background abnormality of the electroencephalography parameters had significant reverse correlations with all heart rate variability parameters. Conclusions We observed a significantly progressive decline in heart rate variability from the day before the neurological deterioration events in patients with severe acute brain injury were first observed.
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Affiliation(s)
- Hyunjo Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang-Soo Lee
- Department of Neurology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lu HY, Huang APH, Kuo LT. Prognostic value of variables derived from heart rate variability in patients with traumatic brain injury after decompressive surgery. PLoS One 2021; 16:e0245792. [PMID: 33539419 PMCID: PMC7861407 DOI: 10.1371/journal.pone.0245792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022] Open
Abstract
Measurement of heart rate variability can reveal autonomic nervous system function. Changes in heart rate variability can be associated with disease severity, risk of complications, and prognosis. We aimed to investigate the prognostic value of heart rate variability measurements in patients with moderate-to-severe traumatic brain injury after decompression surgery. We conducted a prospective study of 80 patients with traumatic brain injury after decompression surgery using a noninvasive electrocardiography device for data collection. Assessment of heart rate variability parameters included the time and frequency domains. The correlations between heart rate variability parameters and one-year mortality and functional outcomes were analyzed. Time domain measures of heart rate variability, using the standard deviation of the RR intervals and the square root of the mean squared differences of successive RR intervals, were statistically significantly lower in the group of patients with unfavorable outcomes and those that died. In frequency domain analysis, very low-frequency and total power were significantly higher in patients with favorable functional outcomes. High-frequency, low-frequency, and total power were statistically significantly higher in patients who survived for more than one year. Multivariate analysis using a model combining age and the Glasgow Coma Scale score with variables derived from heart rate variability substantially improved the prognostic value for predicting long-term outcome. These findings reinforced the concept that traumatic brain injury impacts the brain-heart axis and cardiac autonomic modulation even after decompression surgery, and variables derived from heart rate variability may be useful predictors of outcome.
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Affiliation(s)
- Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Douliou, Yunlin County, Taiwan
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail:
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Utilizing heart rate variability to predict ICU patient outcome in traumatic brain injury. BMC Bioinformatics 2020; 21:481. [PMID: 33308142 PMCID: PMC7734857 DOI: 10.1186/s12859-020-03814-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Prediction of patient outcome in medical intensive care units (ICU) may help for development and investigation of early interventional strategies. Several ICU scoring systems have been developed and are used to predict clinical outcome of ICU patients. These scores are calculated from clinical physiological and biochemical characteristics of patients. Heart rate variability (HRV) is a correlate of cardiac autonomic regulation and has been evident as a marker of poor clinical prognosis. HRV can be measured from the electrocardiogram non-invasively and monitored in real time. HRV has been identified as a promising ‘electronic biomarker’ of disease severity. Traumatic brain injury (TBI) is a subset of critically ill patients admitted to ICU, with significant morbidity and mortality, and often difficult to predict outcomes. Changes of HRV for brain injured patients have been reported in several studies. This study aimed to utilize the continuous HRV collection from admission across the first 24 h in the ICU in severe TBI patients to develop a patient outcome prediction system. Results A feature extraction strategy was applied to measure the HRV fluctuation during time. A prediction model was developed based on HRV measures with a genetic algorithm for feature selection. The result (AUC: 0.77) was compared with earlier reported scoring systems (highest AUC: 0.76), encouraging further development and practical application. Conclusions The prediction models built with different feature sets indicated that HRV based parameters may help predict brain injury patient outcome better than the previously adopted illness severity scores.
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Carrara M, Herpain A, Baselli G, Ferrario M. A Mathematical Model of dP/dt Max for the Evaluation of the Dynamic Control of Heart Contractility in Septic Shock. IEEE Trans Biomed Eng 2019; 66:2719-2727. [PMID: 30872214 DOI: 10.1109/tbme.2019.2894333] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Septic shock (SS) patients often show elevated heart rate (HR) despite resuscitation, and this condition is considered an early manifestation of myocardial dysfunction due to an impairment of autonomic nervous system (ANS). We aimed at proposing a mathematical model to assess the autonomic control of ventricular contractility (VC) and HR to track changes in heart functionality during an experimental animal model of SS and resuscitation. METHODS SS was induced in six adult swine by polymicrobial peritonitis. We analyzed the beat-to-beat variability of the maximum positive time derivative of left ventricular pressure (dP/dt max), heart period (HP), and aortic blood pressure (ABP). We identified the transfer functions relating fluctuations in ABP and HP to dP/dt max to characterize the static and dynamic properties of the arterial baroreflex and the force-frequency relation mechanisms, respectively. Standard indices of autonomic dysfunction have also been considered as HR variability (HRV) and baroreflex sensitivity (BRS). RESULTS During baseline, the baroreflex is predominant in controlling VC with a gain value of -5.8 (-7.5,-3) s-1, compared to -1.2 (-1.9,-0.5) mmHg/s ms-1 of the force-frequency autoregulation. During shock, both mechanisms increase their extent in VC control (higher gains and slightly faster dynamics for the baroreflex). After resuscitation, the physiological control of VC is not restored and all the animals still exhibit high HR and reduced HRV and BRS. CONCLUSION A condition of cardiovascular inefficiency is persistent after resuscitation and this could be due to autonomic dysfunction. SIGNIFICANCE The ANS in SS is crucial to restore homeostasis. Our model could be used to evaluate the efficacy of treatments on VC and related control mechanisms.
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Estévez-Báez M, Machado C, García-Sánchez B, Rodríguez V, Alvarez-Santana R, Leisman G, Carrera JME, Schiavi A, Montes-Brown J, Arrufat-Pié E. Autonomic impairment of patients in coma with different Glasgow coma score assessed with heart rate variability. Brain Inj 2019; 33:496-516. [PMID: 30755043 DOI: 10.1080/02699052.2018.1553312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PRIMARY OBJECTIVE The objective of this study is to assess the functional state of the autonomic nervous system in healthy individuals and in individuals in coma using measures of heart rate variability (HRV) and to evaluate its efficiency in predicting mortality. DESIGN AND METHODS Retrospective group comparison study of patients in coma classified into two subgroups, according to their Glasgow coma score, with a healthy control group. HRV indices were calculated from 7 min of artefact-free electrocardiograms using the Hilbert-Huang method in the spectral range 0.02-0.6 Hz. A special procedure was applied to avoid confounding factors. Stepwise multiple regression logistic analysis (SMLRA) and ROC analysis evaluated predictions. RESULTS Progressive reduction of HRV was confirmed and was associated with deepening of coma and a mortality score model that included three spectral HRV indices of absolute power values of very low, low and very high frequency bands (0.4-0.6 Hz). The SMLRA model showed sensitivity of 95.65%, specificity of 95.83%, positive predictive value of 95.65%, and overall efficiency of 95.74%. CONCLUSIONS HRV is a reliable method to assess the integrity of the neural control of the caudal brainstem centres on the hearts of patients in coma and to predict patient mortality.
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Affiliation(s)
- Mario Estévez-Báez
- a Department of Clinical Neurophysiology , Institute of Neurology and Neurosurgery , Havana , Cuba
| | - Calixto Machado
- a Department of Clinical Neurophysiology , Institute of Neurology and Neurosurgery , Havana , Cuba
| | | | | | | | - Gerry Leisman
- d Faculty of Health Sciences , University of Haifa , Haifa , Israel
| | | | - Adam Schiavi
- e Anesthesiology and Critical Care Medicine, Neurosciences Critical Care Division , Johns Hopkins Hospital , Baltimore , MD , USA
| | - Julio Montes-Brown
- f Department of Medicine & Health Science , University of Sonora , Sonora , Mexico
| | - Eduardo Arrufat-Pié
- g Institute of Basic and Preclinical Sciences, "Victoria de Girón" , Havana , Cuba
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Hasen M, Almojuela A, Zeiler FA. Autonomic Dysfunction and Associations with Functional and Neurophysiological Outcome in Moderate/Severe Traumatic Brain Injury: A Scoping Review. J Neurotrauma 2019; 36:1491-1504. [PMID: 30343625 DOI: 10.1089/neu.2018.6073] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The quantification and objective documentation of autonomic dysfunction in traumatic brain injury (TBI) is neither well studied nor extensively validated. Most of the descriptions of autonomic dysfunction in the literature are in the form of vague non-specific clinical manifestations. Few studies propose the use of objective measures of assessing the extent of autonomic dysfunction to link them to the outcome of TBI. Our goal was to perform a scoping systematic review of the literature on the objective documentation of autonomic dysfunction in terms of functional and physiological variables to be linked to outcome of TBI. PubMed/MEDLINE®, BIOSIS, Scopus, Embase, Cochrane Libraries, and Global Health databases were searched. Two reviewers independently screened the results. Full texts for citations passing this initial screen were obtained. Inclusion and exclusion criteria were applied to each article to obtain final articles for review. The initial search yielded 2619 citations. Of 69 articles selected for final review, 14 were chosen based on the inclusion and exclusion criteria and are included in the results of this article. 9 of these articles assessed autonomic dysfunction using functional variables and 7 assessed autonomic dysfunction using physiological variables. Some studies included both functional and physiological variables. Of the nine studies linking autonomic dysfunction to functional variables, nine included heart rate variability (HRV), three included baroreflex sensitivity (BRS), and two included blood pressure variability (BPV). A total of 2714 adult patients were studied. Although the nature of association between autonomic dysfunction and outcome is unclear, the objective quantification of autonomic dysfunction seems to be associated with global patient outcome and other neurophysiological measures. Further studies are needed to validate its use and explore the underlying molecular mechanisms of the described associations.
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Affiliation(s)
- Mohammed Hasen
- 1 Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,2 Department of Neurosurgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alysa Almojuela
- 1 Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- 1 Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,3 Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,4 Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Abstract
PURPOSE To investigate heart rate and EEG variability and their coupling in patients with sepsis and determine their relationship to sepsis severity and severity of sepsis-associated brain dysfunction. METHODS Fifty-two patients with sepsis were prospectively identified, categorized as comatose (N = 30) and noncomatose (N = 22), and compared with 11 control subjects. In a 30-minute EEG and electrocardiogram recording, heart rate variability and EEG variability (measured by the variability of relative power in a modified alpha band = RAP) and their coupled oscillations were quantified using linear (least-square periodogram and magnitude square coherence) and nonlinear (Shannon entropy and mutual information) measures. These measures were compared between the three groups and correlated with outcome, adjusting for severity of sepsis. RESULTS Several measures of heart rate variability and EEG variability and of their coupled oscillations were significantly lower in patients with sepsis compared with controls and correlated with outcome. This correlation was not independent when adjusting for severity of sepsis. CONCLUSIONS Sepsis is associated with lower variability of both heart rate and RAP on EEG and reduction of their coupled oscillations. This uncoupling is associated with the severity of encephalopathy. Combined EEG and electrocardiogram monitoring may be used to gain insight in underlying mechanisms of sepsis and quantify brainstem or thalamic dysfunction.
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Bento L, Fonseca-Pinto R, Póvoa P. Autonomic nervous system monitoring in intensive care as a prognostic tool. Systematic review. Rev Bras Ter Intensiva 2018; 29:481-489. [PMID: 29340538 PMCID: PMC5764561 DOI: 10.5935/0103-507x.20170072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 04/18/2017] [Indexed: 01/13/2023] Open
Abstract
Objective To present a systematic review of the use of autonomic nervous system
monitoring as a prognostic tool in intensive care units by assessing heart
rate variability. Methods Literature review of studies published until July 2016 listed in
PubMed/Medline and conducted in intensive care units, on autonomic nervous
system monitoring, via analysis of heart rate variability as a prognostic
tool (mortality study). The following English terms were entered in the
search field: ("autonomic nervous system" OR "heart rate variability") AND
("intensive care" OR "critical care" OR "emergency care" OR "ICU") AND
("prognosis" OR "prognoses" OR "mortality"). Results There was an increased likelihood of death in patients who had a decrease in
heart rate variability as analyzed via heart rate variance, cardiac
uncoupling, heart rate volatility, integer heart rate variability, standard
deviation of NN intervals, root mean square of successive differences, total
power, low frequency, very low frequency, low frequency/high frequency
ratio, ratio of short-term to long-term fractal exponents, Shannon entropy,
multiscale entropy and approximate entropy. Conclusion In patients admitted to intensive care units, regardless of the pathology,
heart rate variability varies inversely with clinical severity and
prognosis.
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Affiliation(s)
- Luis Bento
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, EPE - Lisboa, Portugal
| | - Rui Fonseca-Pinto
- Instituto Politécnico de Leiria - Leiria, Portugal.,Instituto de Telecomunicações, MSP - Leiria, Portugal
| | - Pedro Póvoa
- Unidade de Cuidados Intensivos Polivalente, Hospital São Francisco Xavier - Centro Hospitalar de Lisboa Ocidental - Lisboa, Portugal.,NOVA Medical School, CEDOC, Universidade Nova de Lisboa - Lisboa, Portugal
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Deepika A, Devi BI, Shukla D, Sathyaprabha TN, Christopher R, Ramesh SS. Neuroimmunology of Traumatic Brain Injury: A Longitudinal Study of Interdependency of Inflammatory Markers and Heart Rate Variability in Severe Traumatic Brain Injury. J Neurotrauma 2018; 35:1124-1131. [DOI: 10.1089/neu.2017.5151] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Akhil Deepika
- Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Talakad N. Sathyaprabha
- Department of Neurophysiology, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Rita Christopher
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
| | - Shruthi S. Ramesh
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India
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Autonomic Impairment in Severe Traumatic Brain Injury: A Multimodal Neuromonitoring Study. Crit Care Med 2017; 44:1173-81. [PMID: 26968025 DOI: 10.1097/ccm.0000000000001624] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Autonomic impairment after acute traumatic brain injury has been associated independently with both increased morbidity and mortality. Links between autonomic impairment and increased intracranial pressure or impaired cerebral autoregulation have been described as well. However, relationships between autonomic impairment, intracranial pressure, impaired cerebral autoregulation, and outcome remain poorly explored. Using continuous measurements of heart rate variability and baroreflex sensitivity we aimed to test whether autonomic markers are associated with functional outcome and mortality independently of intracranial variables. Further, we aimed to evaluate the relationships between autonomic functions, intracranial pressure, and cerebral autoregulation. DESIGN Retrospective analysis of a prospective database. SETTING Neurocritical care unit in a university hospital. SUBJECTS Sedated patients with severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Waveforms of intracranial pressure and arterial blood pressure, baseline Glasgow Coma Scale and 6 months Glasgow Outcome Scale were recorded. Baroreflex sensitivity was assessed every 10 seconds using a modified cross-correlational method. Frequency domain analyses of heart rate variability were performed automatically every 10 seconds from a moving 300 seconds of the monitoring time window. Mean values of baroreflex sensitivity, heart rate variability, intracranial pressure, arterial blood pressure, cerebral perfusion pressure, and impaired cerebral autoregulation over the entire monitoring period were calculated for each patient. Two hundred and sixty-two patients with a median age of 36 years entered the analysis. The median admission Glasgow Coma Scale was 6, the median Glasgow Outcome Scale was 3, and the mortality at 6 months was 23%. Baroreflex sensitivity (adjusted odds ratio, 0.9; p = 0.02) and relative power of a high frequency band of heart rate variability (adjusted odds ratio, 1.05; p < 0.001) were individually associated with mortality, independently of age, admission Glasgow Coma Scale, intracranial pressure, pressure reactivity index, or cerebral perfusion pressure. Baroreflex sensitivity showed no correlation with intracranial pressure or cerebral perfusion pressure; the correlation with pressure reactivity index was strong in older patients (age, > 60 yr). The relative power of high frequency correlated significantly with intracranial pressure and cerebral perfusion pressure, but not with pressure reactivity index. The relative power of low frequency correlated significantly with pressure reactivity index. CONCLUSIONS Autonomic impairment, as measured by heart rate variability and baroreflex sensitivity, is significantly associated with increased mortality after traumatic brain injury. These effects, though partially interlinked, seem to be independent of age, trauma severity, intracranial pressure, or autoregulatory status, and thus represent a discrete phenomenon in the pathophysiology of traumatic brain injury. Continuous measurements of heart rate variability and baroreflex sensitivity in the neuromonitoring setting of severe traumatic brain injury may carry novel pathophysiological and predictive information.
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Respiratory induced heart rate variability during slow mechanical ventilation : Marker to exclude brain death patients. Wien Klin Wochenschr 2017; 129:251-258. [PMID: 28236042 DOI: 10.1007/s00508-017-1176-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 01/29/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Respiratory induced heart rate variability (rHRV) was analysed in mechanically ventilated patients during two levels of sedation and brain death. Our aim was to determine whether rHRV can distinguish between different levels of sedation and especially between brain death and sedated patients. METHODS In this study 30 critically ill and 23 brain death patients were included and four respiratory rates of 15, 12, 8 and 6 breaths per minute, each lasting 5 min were used. Two sedation levels, basal and deep, were performed in the critically ill patients. Heart rate and blood pressure changes induced by ventilation were subsequently detected and analysed. RESULTS Significant differences were found in rHRV and rHRV adjusted for tidal volume (rHRV/VT) between critically ill and brain death patients during slow breathing at 6 or 8 breaths per minute. The rHRV at 6 breaths per minute was below 15 ms in all brain death subjects except one. The rHRV/VT was lower than 25 ms/l at both 6 and 8 breaths per minute in all brain death patients and simultaneously at 75% of non-brain death patients was higher (specificity 1, sensitivity 0.24). Differences in rHRV and rHRV/VTs between basal and deep sedation were not significant. CONCLUSIONS The main clinical benefit of the study is the finding that rHRV and rHRV/VT during 6 and 8 breaths per minute can differentiate between critically ill and brain death patients. An rHRV/VT exceeding 25 ms/l reliably excludes brain death.
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Heart Rate Variability Predicts Neurogenic Pulmonary Edema in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2015; 25:71-8. [DOI: 10.1007/s12028-015-0237-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Heart rate variability in hypoxic ischemic encephalopathy: correlation with EEG grade and 2-y neurodevelopmental outcome. Pediatr Res 2015; 77:681-7. [PMID: 25665054 DOI: 10.1038/pr.2015.28] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/04/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND The study aims to describe heart rate variability (HRV) in neonatal hypoxic ischemic encephalopathy (HIE) and correlate HRV with electroencephalographic (EEG) grade of HIE and neurodevelopmental outcome. METHODS Multichannel EEG and electrocardiography (ECG) were assessed at 12-48 h after birth in healthy and encephalopathic full-term neonates. EEGs were graded (normal, mild, moderate, and severe). Neurodevelopmental outcome was assessed at 2 y of age. Seven HRV features were calculated using normalized-RR (NN) interval. The correlation of these features with EEG grade and outcome were measured using Spearman's correlation coefficient. RESULTS HRV was significantly associated with HIE severity (P < 0.05): standard deviation of NN interval (SDNN) (r = -0.62), triangular interpolation of NN interval histogram (TINN) (r = -0.65), mean NN interval (r = -0.48), and the very low frequency (VLF) (r = -0.60), low frequency (LF) (r = -0.67) and high frequency (HF) components of the NN interval (r = -0.60). SDNN at 24 and 48 h were significantly associated (P < 0.05) with neurodevelopmental outcome (r = -0.41 and -0.54, respectively). CONCLUSION HRV is associated with EEG grade of HIE and neurodevelopmental outcome. HRV has potential as a prognostic tool to complement EEG.
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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Heart rate variability in encephalopathic newborns during and after therapeutic hypothermia. J Perinatol 2014; 34:836-41. [PMID: 24921413 PMCID: PMC4216618 DOI: 10.1038/jp.2014.108] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/11/2014] [Accepted: 04/11/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate whether heart rate variability (HRV) measures are predictive of neurological outcome in babies with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN This case-control investigation included 20 term encephalopathic newborns treated with systemic hypothermia in a regional neonatal intensive care unit. Electrocardiographic data were collected continuously during hypothermia. Spectral analysis of beat-to-beat heart rate interval was used to quantify HRV. HRV measures were compared between infants with adverse outcome (death or neurodevelopmental impairment at 15 months, n = 10) and those with favorable outcome (survivors without impairment, n = 10). RESULT HRV differentiated infants by outcome during hypothermia through post-rewarming, with the best distinction between groups at 24 h and after 80 h of life. CONCLUSION HRV during hypothermia treatment distinguished HIE babies who subsequently died or had neurodevelopmental impairment from intact survivors. This physiological biomarker may identify infants in need of adjuvant neuroprotective interventions. These findings warrant further investigation in a larger population of infants with HIE.
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Schmidt H, Lotze U, Ghanem A, Anker S, Said S, Braun-Dullaeus R, Oltmanns G, Rose S, Buerke M, Müller-Werdan U, Werdan K, Rauchhaus M. Relation of impaired interorgan communication and parasympathetic activity in chronic heart failure and multiple-organ dysfunction syndrome. J Crit Care 2014; 29:367-73. [DOI: 10.1016/j.jcrc.2013.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 11/17/2013] [Accepted: 12/22/2013] [Indexed: 11/28/2022]
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Mazzeo AT, Micalizzi A, Mascia L, Scicolone A, Siracusano L. Brain-heart crosstalk: the many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care. Br J Anaesth 2014; 112:803-15. [PMID: 24638232 DOI: 10.1093/bja/aeu046] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Neurogenic stress cardiomyopathy (NSC) is a well-known syndrome complicating the early phase after an acute brain injury, potentially affecting outcomes. This article is a review of recent data on the putative role of localization and lateralization of brain lesions in NSC, cardiac innervation abnormalities, and new polymorphisms and other genetic causes of the sympathetic nervous system over-activity. Concerns regarding the management of stress-related cardiomyopathy syndromes during the perioperative period are also discussed. Future clinical research should explore whether specific factors explain different patient susceptibilities to the disease and should be directed towards early identification and stratification of patients at risk, so that such patients can be more carefully monitored and appropriately managed in critical care and during the perioperative period.
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Affiliation(s)
- A T Mazzeo
- Department of Anaesthesia and Intensive Care, University of Torino, Azienda Ospedaliera Citta' della Salute e della Scienza di Torino, Presidio Molinette, Corso Dogliotti 14, 10126 Torino, Italy
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Kox M, Vrouwenvelder MQ, Pompe JC, van der Hoeven JG, Pickkers P, Hoedemaekers CW. The effects of brain injury on heart rate variability and the innate immune response in critically ill patients. J Neurotrauma 2012; 29:747-55. [PMID: 22111862 DOI: 10.1089/neu.2011.2035] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Brain injury and its related increased intracranial pressure (ICP) may lead to increased vagus nerve activity and the subsequent suppression of innate immunity via the cholinergic anti-inflammatory pathway. This may explain the observed increased susceptibility to infection in these patients. In the present study, we investigated the association between brain injury, vagus nerve activity, and innate immunity. We determined heart rate variability (HRV) as a measure of vagus nerve activity, plasma cytokines, and cytokine production of ex vivo lipopolysaccharide-stimulated whole blood in the first 4 days of admission to the neurological intensive care unit (ICU) in 34 patients with various forms of brain damage. HRV, immune parameters, and the correlations between these measures were analyzed in the entire group of patients and in subgroups of patients with conditions associated with high (intracranial hemorrhage [ICH]) and normal ICP (subarachnoid hemorrhage [SAH] with an extraventricular drain alleviating ICP). Healthy volunteers were used for comparison. HRV total spectral power and ex vivo-stimulated cytokine production were severely depressed in patients compared with healthy volunteers (p<0.05). Furthermore, HRV analysis showed that normalized units of high-frequency power (HFnu, corresponding with vagus nerve activity) was higher, and the low-frequency:high-frequency ratio (LF:HF, corresponding with sympathovagal balance) was lower in patients compared to healthy volunteers (p<0.05). HFnu correlated inversely with ex vivo-stimulated tumor necrosis factor-α (TNF-α) production (r=-0.22, p=0.025). The most pronounced suppression of ex vivo-stimulated cytokine production was observed in the ICH group. Furthermore, in ICH patients, HFnu correlated strongly with lower plasma TNF-α levels (r=-0.73, p=0.002). Our data suggest that brain injury, and especially conditions associated with increased ICP, is associated with vagus nerve-mediated immune suppression.
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Affiliation(s)
- Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands.
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Jurák P, Zvoníček V, Leinveber P, Halámek J, Vondra V. Respiratory induced heart rate and blood pressure variability during mechanical ventilation in critically ill and brain death patients. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2012; 2012:3821-3824. [PMID: 23366761 DOI: 10.1109/embc.2012.6346800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
UNLABELLED We analysed respiratory induced heart rate and blood pressure variability in mechanically ventilated patients with different levels of sedation and central nervous system activity. Our aim was to determine whether it is possible to distinguish different levels of sedation or human brain activity from heart rate and blood pressure. We measured 19 critically ill and 15 brain death patients ventilated at various respiratory frequencies - 15, 12, 8 and 6 breaths per minute. Basal and deeper sedation was performed in the critically ill patients. We detected and analysed heart rate and blood pressure parameters induced by ventilation. RESULTS Respiratory induced heart rate variability is the unique parameter that can differentiate between brain death patients and sedated critically ill patients. Significant differences exist, especially during slow deep breathing with a mean period of 10 seconds. The limit values reflecting brain death are: baroreflex lower than 0.5 ms/mmHg and tidal volume normalised heart rate variability lower than 0.5 ms/ml. Reduced heart rate variability parameters of brain death patients remain unchanged even after normalisation to respiration volume. However, differences between basal and deep sedation do not appear significant on any parameter.
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Affiliation(s)
- P Jurák
- Institute of Scientific Instruments, Academy of Sciences of the Czech Republic, Brno, Czech Republic.
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Heart rate variability is an independent predictor of morbidity and mortality in hemodynamically stable trauma patients. ACTA ACUST UNITED AC 2011; 70:1371-80. [PMID: 21817974 DOI: 10.1097/ta.0b013e31821858e6] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reduced heart rate variability (HRV) reflects autonomic dysfunction and can triage patients better than routine trauma criteria or vital signs. However, there is questionable specificity and no consensus measurement technique. The purpose of this study was to analyze whether factors that alter autonomic function affect the specificity of HRV for assessing traumatic injury. METHODS We evaluated 216 hemodynamically stable adults (3:1 M:F; 97:3 blunt:penetrating; age 49 years ± 1 year, mean ± standard error) undergoing computed axial tomography (CT) scan to rule out traumatic brain injury (TBI). All were prospectively instrumented with a Mars Holter system (GE Healthcare, Milwaukee, WI). HRV was determined offline using time domain (standard deviation of normal-normal intervals, root-mean-square successive difference) and frequency domain (very low frequency [VLF], LF, wideband frequency, high frequency [HF], low to HF index ratio) calculations from 15-minute electrocardiogram and correlated with routine vital signs, mortality, TBI, morbidity, length of stay (LOS), and comorbidities. Significance (p ≤ 0.05) was determined using nonparametric analysis, Student's t test, analysis of variance, or multiple logistic regression. RESULTS VLF alone predicted survival, severity of TBI, intensive care unit LOS, and hospital LOS (all p < 0.05). Beta-blockers or diabetes had no effect, whereas age, sedation, mechanical ventilation, spinal cord injury, and intoxication influenced one or more of the variables with age being the most powerful confounder (all p < 0.05). Except for the Glasgow Coma Scale, no other routine trauma or hemodynamic criteria correlated with any of these outcomes. CONCLUSIONS Decreased VLF is an independent predictor of mortality and morbidity in hemodynamically stable trauma patients. Other time and other frequency domain variables correlated with some, but not all, outcomes. All were heavily influenced by factors that alter autonomic function, especially patient age.
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Mazzeo AT, La Monaca E, Di Leo R, Vita G, Santamaria LB. Heart rate variability: a diagnostic and prognostic tool in anesthesia and intensive care. Acta Anaesthesiol Scand 2011; 55:797-811. [PMID: 21658013 DOI: 10.1111/j.1399-6576.2011.02466.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The autonomic nervous system (ANS) plays an important role in the human response to various internal and external stimuli, which can modify homeostasis, and exerts a tight control on essential functions such as circulation, respiration, thermoregulation and hormonal secretion. ANS dysfunction may complicate the perioperative course in the surgical patient undergoing anesthesia, increasing morbidity and mortality, and, therefore, it should be considered as an additional risk factor during pre-operative evaluation. Furthermore, ANS dysfunction may complicate the clinical course of critically ill patients admitted to intensive care units, in the case of trauma, sepsis, neurologic disorders and cardiovascular diseases, and its occurrence adversely affects the outcome. In the care of these patients, the assessment of autonomic function may provide useful information concerning pathophysiology, risk stratification, early prognosis prediction and treatment strategies. Given the role of ANS in the maintenance of systemic homeostasis, anesthesiologists and intensivists should recognize as critical the evaluation of ANS function. Measurement of heart rate variability (HRV) is an easily accessible window into autonomic activity. It is a low-cost, non-invasive and simple to perform method reflecting the balance of the ANS regulation of the heart rate and offers the opportunity to detect the presence of autonomic neuropathy complicating several illnesses. The present review provides anesthesiologists and intensivists with a comprehensive summary of the possible clinical implications of HRV measurements, suggesting that autonomic dysfunction testing could potentially represent a diagnostic and prognostic tool in the care of patients both in the perioperative setting as well as in the critical care arena.
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Affiliation(s)
- Anna Teresa Mazzeo
- Anaesthesia and NeuroIntensive Care Unit, Department of Neurosciences, Psychiatry and Anaesthesiology, University of Messina, Messina, Italy.
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Wallén MB, Hasson D, Theorell T, Canlon B, Osika W. Possibilities and limitations of the polar RS800 in measuring heart rate variability at rest. Eur J Appl Physiol 2011; 112:1153-65. [DOI: 10.1007/s00421-011-2079-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 07/05/2011] [Indexed: 12/29/2022]
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Chiu TF, Huang CC, Chen JH, Chen WL. Depressed sympathovagal balance predicts mortality in patients with subarachnoid hemorrhage. Am J Emerg Med 2011; 30:651-6. [PMID: 21570235 DOI: 10.1016/j.ajem.2011.02.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 02/26/2011] [Accepted: 02/27/2011] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The objective of this study is to investigate the role of sympathovagal balance in predicting inhospital mortality by assessing power spectral analysis of heart rate variability (HRV) among patients with nontraumatic subarachnoid hemorrhage (SAH) in an emergency department (ED). METHODS A cohort of 132 adult patients with spontaneous SAH in an ED was prospectively enrolled. A continuous 10-minute electrocardiography for off-line power spectral analysis of the HRV was recorded. Using the inhospital mortality, the patients were classified into 2 groups: nonsurvivors (n=38) and survivors (n=94). The HRV measures were compared between these 2 groups of patients. RESULTS Having compared the various measurements, the very low-frequency component, low-frequency component, normalized low-frequency component (LF%), and low-/high-frequency component ratio (LF/HF) were significantly lower, whereas the normalized high-frequency component was significantly higher among the nonsurvivors than among the survivors. A multiple logistic regression model identified LF/HF (odds ratio, 2.16; 95% confidence interval [CI], 1.18-3.97; P=.013) and LF% (odds ratio, 0.78; 95% CI, 0.69-0.88; P<.001) as independent variables that were able to predict inhospital mortality for patients with SAH in an ED. The receiver operating characteristic area for LF/HF in predicting inhospital mortality was 0.957 (95% CI, 0.914-1.000; P<.001), and the best cutoff points was 0.8 (sensitivity, 92.1%; specificity, 90.4%). CONCLUSIONS Power spectral analysis of the HRV is able to predict inhospital mortality for patients after SAH in an ED. A tilt in the sympathovagal balance toward depressed sympathovagal balance, as indicated by HRV analysis, might contribute to the poor outcome among these patients.
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Affiliation(s)
- Te-Fa Chiu
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou Branch, Chang Gung University College of Medicine, Tao-Yuan 333, Taiwan
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Heart Rate and Pulse Pressure Variability are Associated With Intractable Intracranial Hypertension After Severe Traumatic Brain Injury. J Neurosurg Anesthesiol 2010; 22:296-302. [DOI: 10.1097/ana.0b013e3181e25fc3] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dünser MW, Hasibeder WR. Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress. J Intensive Care Med 2009; 24:293-316. [PMID: 19703817 DOI: 10.1177/0885066609340519] [Citation(s) in RCA: 322] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The term ''adrenergic'' originates from ''adrenaline'' and describes hormones or drugs whose effects are similar to those of epinephrine. Adrenergic stress is mediated by stimulation of adrenergic receptors and activation of post-receptor pathways. Critical illness is a potent stimulus of the sympathetic nervous system. It is undisputable that the adrenergic-driven ''fight-flight response'' is a physiologically meaningful reaction allowing humans to survive during evolution. However, in critical illness an overshooting stimulation of the sympathetic nervous system may well exceed in time and scope its beneficial effects. Comparable to the overwhelming immune response during sepsis, adrenergic stress in critical illness may get out of control and cause adverse effects. Several organ systems may be affected. The heart seems to be most susceptible to sympathetic overstimulation. Detrimental effects include impaired diastolic function, tachycardia and tachyarrhythmia, myocardial ischemia, stunning, apoptosis and necrosis. Adverse catecholamine effects have been observed in other organs such as the lungs (pulmonary edema, elevated pulmonary arterial pressures), the coagulation (hypercoagulability, thrombus formation), gastrointestinal (hypoperfusion, inhibition of peristalsis), endocrinologic (decreased prolactin, thyroid and growth hormone secretion) and immune systems (immunomodulation, stimulation of bacterial growth), and metabolism (increase in cell energy expenditure, hyperglycemia, catabolism, lipolysis, hyperlactatemia, electrolyte changes), bone marrow (anemia), and skeletal muscles (apoptosis). Potential therapeutic options to reduce excessive adrenergic stress comprise temperature and heart rate control, adequate use of sedative/analgesic drugs, and aiming for reasonable cardiovascular targets, adequate fluid therapy, use of levosimendan, hydrocortisone or supplementary arginine vasopressin.
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Affiliation(s)
- Martin W Dünser
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse, Innsbruck, Austria.
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Morris JA, Norris PR, Moore JH, Jenkins JM, Williams AE, Canter JA. Genetic Variation in the Autonomic Nervous System Affects Mortality: A Study of 1,095 Trauma Patients. J Am Coll Surg 2009; 208:663-8; discussion 668-70. [DOI: 10.1016/j.jamcollsurg.2008.12.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 12/02/2008] [Indexed: 12/01/2022]
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Tiainen M, Parikka HJ, Mäkijärvi MA, Takkunen OS, Sarna SJ, Roine RO. Arrhythmias and heart rate variability during and after therapeutic hypothermia for cardiac arrest*. Crit Care Med 2009; 37:403-9. [DOI: 10.1097/ccm.0b013e31819572c4] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Investigation of heart rate and blood pressure variability, baroreflex sensitivity, and approximate entropy in acute brain injury patients. J Crit Care 2008; 23:380-6. [DOI: 10.1016/j.jcrc.2007.04.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Revised: 04/04/2007] [Accepted: 04/13/2007] [Indexed: 11/21/2022]
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Autonomic dysfunction predicts both 1- and 2-month mortality in middle-aged patients with multiple organ dysfunction syndrome. Crit Care Med 2008; 36:967-70. [PMID: 18431287 DOI: 10.1097/ccm.0b013e3181653263] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Multiple organ dysfunction syndrome (MODS) is a disease entity that carries a high mortality rate. It is characterized by a sequential failure of several organ systems after a trigger event, most commonly sepsis. There is increasing evidence that autonomic dysfunction may substantially contribute to the development of MODS. We recently characterized the spectrum of autonomic dysfunction by using heart rate variability in critically ill MODS patients and were able to show that autonomic dysfunction predicts 28-day mortality in MODS. The aim of the present study was evaluate whether autonomic dysfunction is also a predictor of 180-day and 365-day mortalities. DESIGN Prospective cohort study. SETTING Twelve-bed medical intensive care unit in a university center. PATIENTS Ninety consecutively admitted score-defined MODS patients. INTERVENTIONS We assessed heart rate variability as a marker of autonomic dysfunction. The patients were followed for 180- and 365-day mortalities. MEASUREMENTS AND MAIN RESULTS We prospectively used the heart rate variability variable lnVLF, which predicted 28-day mortality best in the entire cohort of patients, for analysis of longer term mortality. The variable lnVLF was found to be useful for risk prediction for about 60 days, and then the survival curves became nearly parallel. CONCLUSIONS Autonomic function of critically ill MODS patients is blunted, and this attenuation has prognostic implications not merely concerning 28-day mortality but also concerning longer term (about 2-month) mortality.
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Schmidt H, Hoyer D, Wilhelm J, Söffker G, Heinroth K, Hottenrott K, Said SM, Buerke M, Müller-Werdan U, Werdan K. The alteration of autonomic function in multiple organ dysfunction syndrome. Crit Care Clin 2008; 24:149-63, ix. [PMID: 18241783 DOI: 10.1016/j.ccc.2007.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Autonomic dysfunction is associated with the severity of illness and mortality in patients with multiple organ dysfunction syndrome (MODS) and may contribute significantly to the pathogenesis of this syndrome. Several treatment approaches may possibly restore autonomic function in MODS and thus cause the survival benefit.
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Affiliation(s)
- Hendrik Schmidt
- Martin-Luther-University Halle-Wittenberg, Klinikum Kröllwitz, Ernst-Grube-Strasse 40, D-06097 Halle/Saale, Germany.
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Beta-blocker exposure in patients with severe traumatic brain injury (TBI) and cardiac uncoupling. ACTA ACUST UNITED AC 2008; 63:503-10; discussion 510-1. [PMID: 18073593 DOI: 10.1097/ta.0b013e3181271c34] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac uncoupling and reduced heart rate (HR) variability are associated with increased mortality after severe traumatic brain injury (TBI). Recent data has shown beta-blocker (betaB) exposure is associated with improved survival in this patient population. The purpose of the present study was to evaluate the effect of betaB exposure on the mortality risk of patients with severe TBI and early cardiac uncoupling. METHODS From December 2000 to October 2005, 4,116 patients were admitted to the trauma intensive care unit. Four hundred forty-six patients (12%) had head Abbreviated Injury Scale score >/= 5 without neck injury and had continuous HR data for the first 24 hours. One hundred forty-one patients (29%) received betaB. Cardiac uncoupling was calculated as the percent of time that 5-minute HR standard deviation was between 0.3 bpm and 0.6 bpm on postinjury day 1. RESULTS A relationship between betaB and survival was observed when the population was considered irrespective of length of stay or betaB start time (p < 0.001). Cardiac uncoupling appears to stratify patients into groups who might receive additional benefit from betaB, and identifies patients with increasing mortality. However, the association of betaB with survival was attenuated when analyses accounted for selection bias in betaB administration. CONCLUSIONS betaB exposure was associated with reduced mortality among patients with severe TBI. Though loss of HR variability has previously been associated with an increase in mortality, betaB exposure appears to be associated with increased survival across all stratifications of cardiac uncoupling.
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Schmidt H, Müller-Werdan U, Werdan K. Autonomic Dysfunction: A Relevant Component in Multiple Organ Dysfunction Syndrome. Intensive Care Med 2007. [DOI: 10.1007/978-0-387-49518-7_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Morris JA, Norris PR, Waitman LR, Ozdas A, Guillamondegui OD, Jenkins JM. Adrenal insufficiency, heart rate variability, and complex biologic systems: a study of 1,871 critically ill trauma patients. J Am Coll Surg 2007; 204:885-92; discussion 892-3. [PMID: 17481504 DOI: 10.1016/j.jamcollsurg.2007.01.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 01/10/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reduction in integer heart rate variability (HRVi), one potential measurement of complex biologic systems, is common in ICU patients and is strongly associated with hospital mortality. Adrenal insufficiency (AI) and reduced HRVi are associated with autonomic dysfunction. Failure of the autonomic nervous system can be associated with loss of biologic complexity. We hypothesize decreased HRVi is associated with AI, and HRVi improves after treatment of AI, suggesting "recomplexification" (resumption of normal stress response to injury). STUDY DESIGN Of 4,116 trauma ICU admissions from December 2000 to November 2005, 1,871 patients had sufficient physiologic, laboratory, pharmacy, and demographic data for analysis. Seventy-five patients failing cosyntropin-stimulation testing were defined as AI; the remaining 1,796 were defined as no AI. HRVi was calculated as integer heart rate standard deviation over 5-minute intervals. HRVi 10th, 50th (median), and 90th percentiles were calculated over the 72 hours pre-, or poststeroid, or both administration (AI). HRVi percentiles in non-AI patients were evaluated at the same interval and compared with AI using Wilcoxon's rank-sum test. In patients with AI, daily HRVi was computed 3 days before and after steroid administration, and compared between survivors and nonsurvivors. RESULTS There were 2.9 million heart-rate intervals measured. HRVi stratified patients with AI (cosyntropin failure), and without AI. HRVi was similar in AI survivors and nonsurvivors before steroid treatment, but differed after treatment. HRVi increased substantially in survivors after steroid administration, yet did not change in nonsurvivors. HRVi does not increase in patients who are unresponsive to steroids and die. CONCLUSIONS Reduced heart-rate variability, a potential measurement of complex biologic systems, is associated with cosyntropin-confirmed AI; improved in patients responding to steroid therapy; and is a noninvasive, real-time biomarker suggesting AI.
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Affiliation(s)
- John A Morris
- Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37212, USA.
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Norris PR, Ozdas A, Cao H, Williams AE, Harrell FE, Jenkins JM, Morris JA. Cardiac uncoupling and heart rate variability stratify ICU patients by mortality: a study of 2088 trauma patients. Ann Surg 2006; 243:804-12; discussion 812-4. [PMID: 16772784 PMCID: PMC1570581 DOI: 10.1097/01.sla.0000219642.92637.fd] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We have previously shown that cardiac uncoupling (reduced heart rate variability) in the first 24 hours of trauma ICU stay is a robust predictor of mortality. We hypothesize that cardiac uncoupling over the entire ICU stay independently predicts mortality, reveals patterns of injury, and heralds complications. METHODS A total of 2088 trauma ICU patients satisfied the inclusion criteria for this study. Cardiac uncoupling by outcome was compared using the Wilcoxon rank sum test. Risk of death from cardiac uncoupling and covariates (age, ISS, AIS Head Score, total transfusion requirements) was assessed using multivariate logistic regression models at each ICU day. Univariate logistic regression was used to assess risk of death from uncoupling irrespective of covariates at each ICU day. RESULTS A total of 1325 (63.5%) patients displayed some degree of uncoupling over their ICU stay. The difference in uncoupling between survivors and nonsurvivors is both dramatic and consistent across the entire ICU stay, indicating that the presence of uncoupling is unrelated to the cause of death. However, the magnitude of uncoupling varies by day when data is stratified by cause of death. CONCLUSIONS Cardiac uncoupling: 1) is an independent predictor of death throughout the ICU stay, 2) has a predictive window of 2 to 4 days, and 3) appears to increase in response to inflammation, infection, and multiple organ failure.
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Affiliation(s)
- Patrick R Norris
- Section of Surgical Sciences, Department of Biomedical Engineering, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, TN 37212, USA
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Gujjar AR, Sathyaprabha TN, Nagaraja D, Thennarasu K, Pradhan N. Heart rate variability and outcome in acute severe stroke: role of power spectral analysis. Neurocrit Care 2006; 1:347-53. [PMID: 16174933 DOI: 10.1385/ncc:1:3:347] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Heart rate variability (HRV) is a predictor of outcome in acute myocardial infarction and head trauma. Its efficacy in predicting outcome in stroke has not been well documented. MATERIALS AND METHODS Twenty-five patients (mean age 39 years) with acute stroke treated in a stroke intensive care unit were studied. Continuous echocardiogram recorded for a 1-hour period was digitized and stored for off-line analysis. Time and frequency domain HRV measures were derived for the filtered and rectified ECG data for each patient. Clinical and HRV profiles were compared among patients who died or survived. RESULTS At admission, 16 patients were comatose (Glasgow Coma score<9 at admission), 16 had focal weakness, and all had abnormal brain computed tomography. Of the 25 patients,11 died, 10 had a poor outcome, and 4 had good outcome. Two variables low-frequency (LF) spectral power and very low-frequency (VLF) spectral power correlated with mortality. After adjustment for mechanical ventilation and vasopressor administration, LF, VLF, and Triangular index of RR interval (TINN) correlated with mortality. On multiple regression analysis weighed for mechanical ventilation and vasopressor administration, the eye-opening score on Glasgow Coma Scale and LF spectral power were factors that were independently predictive of mortality. CONCLUSION HRV measurements are independent predictors of outcome in acute severe stroke.
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Affiliation(s)
- Arunodaya R Gujjar
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
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Morris JA, Norris PR. Role of reduced heart rate volatility in predicting death in trauma patients. Adv Surg 2005; 39:77-96. [PMID: 16250547 DOI: 10.1016/j.yasu.2005.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- John A Morris
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Schmidt H, Müller-Werdan U, Hoffmann T, Francis DP, Piepoli MF, Rauchhaus M, Prondzinsky R, Loppnow H, Buerke M, Hoyer D, Werdan K. Autonomic dysfunction predicts mortality in patients with multiple organ dysfunction syndrome of different age groups. Crit Care Med 2005; 33:1994-2002. [PMID: 16148471 DOI: 10.1097/01.ccm.0000178181.91250.99] [Citation(s) in RCA: 208] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Multiple organ dysfunction syndrome (MODS) is the sequential failure of several organ systems after a trigger event, like sepsis or cardiogenic shock. Mortality rate is high, up to 70%. Autonomic dysfunction may substantially contribute to the development of MODS. Our study aimed to characterize a) the spectrum of autonomic dysfunction of critically ill MODS patients; b) whether autonomic dysfunction is different in patients receiving sedation, mechanical ventilation, or catecholamines; c) the age dependency of autonomic dysfunction in MODS; and d) whether autonomic dysfunction predicts mortality in MODS. DESIGN Prospective cohort study. SETTING Twelve-bed medical intensive care unit in a university center. PATIENTS Ninety consecutively admitted score-defined MODS patients. INTERVENTIONS Assessment of heart rate variability, baroreflex sensitivity, and chemoreflex sensitivity as markers of autonomic dysfunction. The patients were followed for 28-day mortality. MEASUREMENTS AND MAIN RESULTS Baroreflex sensitivity, chemoreflex sensitivity, and almost all indexes of heart rate variability were attenuated in comparison to normal range data. There was no association between the assessed heart rate variability variables, baroreflex sensitivity or chemoreflex sensitivity, and the presence of sedation or catecholamine therapy. Except for frequency-domain variables, pNN50 (percentage of differences of successive RR intervals differing >50 msecs) and rMSSD (root mean square of successive difference of N-N intervals), none of the measured variables were related to the presence of mechanical ventilation. Age dependency was detected for baroreflex sensitivity but not for heart rate variability indexes or chemoreflex sensitivity (across ages 24-96 yrs). lnVLF predicted 28-day mortality best in the entire cohort of patients and in a subgroup of patients with cardiogenic-triggered MODS. CONCLUSIONS Autonomic function of MODS patients is blunted, and this attenuation has prognostic implications. The extensive influence of MODS on autonomic function overwhelms and masks the well-known age dependency of autonomic function seen in healthy persons.
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Norris PR, Morris JA, Ozdas A, Grogan EL, Williams AE. Heart Rate Variability Predicts Trauma Patient Outcome as Early as 12 h: Implications for Military and Civilian Triage. J Surg Res 2005; 129:122-8. [PMID: 15978622 DOI: 10.1016/j.jss.2005.04.024] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2005] [Revised: 04/07/2005] [Accepted: 04/13/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our previous work demonstrated dense physiological data capture in the intensive care unit (ICU), defined a new vital sign Cardiac Volatility Related Dysfunction (CVRD) reflecting reduced heart rate variability, and demonstrated CVRD predicts death during the hospital stay adjusting for age and injury severity score (ISS). We hypothesized a more precise definition of variability in integer heart rate improves predictive power earlier in ICU stay, without adjusting for covariates. METHODS Approximately 120 million integer heart rate (HR) data points were prospectively collected and archived from 1316 trauma ICU patients, linked to outcome data, and de-identified. HR standard deviation was computed in each 5-min interval (HR(SD5)). HR(SD5) logistic regression identified ranges predictive of death. The study group was randomly divided. Integer heart rate variability (% time HR(SD5) in predictive distribution ranges) models were developed on the first set (N = 658) at 1, 2, 4, 6, 8, 12, and 24 h after ICU admission, and validated on the second set (N = 658). RESULTS HR(SD5) is bimodal, predicts death at low (0.1-0.9 bpm) and survival at high (1.8-2.6 bpm) ranges. HRV predicts death as early as 12 h (ROC = 0.67). HRV in a moving 1-h window is a simple graphic display technique. CONCLUSIONS Dense physiological data capture allows calculation of HRV, which: 1) Independently predicts hospital death in trauma patients at 12 h; 2) Shows early differences by mortality in groups of patients when viewed in a moving window; and 3) May have implications for military and civilian triage.
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Affiliation(s)
- Patrick R Norris
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA
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Jakob SM, Parviainen I, Ruokonen E, Uusaro A, Takala J. Lack of effect of ranitidine on gastric luminal pH and mucosal PCO2 during the first day in the ICU. Acta Anaesthesiol Scand 2005; 49:390-6. [PMID: 15752407 DOI: 10.1111/j.1399-6576.2005.00651.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Histamine(2) (H(2))-blocking agents can attenuate intragastric CO(2)-production by reducing gastric acid secretion and preventing the interaction between H(+) and bicarbonate. However, gastric acid production may be impaired in acute circulatory failure due to poor mucosal perfusion, and H(2)-blockade could further impair mucosal perfusion. METHODS Forty patients with acute circulatory and/or respiratory failure, age 61 +/- 16 years (mean +/- SD), APACHE II score 21 +/- 7, and SOFA score 8 +/- 3, received randomly either ranitidine, 50 mg (R) or placebo (P) every 8 h. Gastric intraluminal pH (gpH; antimony probe with external reference electrode) and mucosal pCO(2) (prCO(2), semicontinuous air-tonometry) were measured during 24 h, and blood gases were taken at 6-h intervals. RESULTS Gastric intraluminal pH was 4.3 +/- 2.4 in P and 5.1 +/- 1.6 in R (NS). Mean prCO(2) was 6.8 +/- 2.7 kPa in P and 7.4 +/- 2.1 kPa in R, and mucosal-arterial pCO(2) gradient (Delta pCO(2)) was 2.2 +/- 2.9 kPa and 2.4 +/- 2.4 kPa, respectively (NS). Within-patient variabilities of gpH and prCO(2) were not influenced by ranitidine. A posthoc analysis revealed that non-survival in R was associated with a low mucosal pHi after 24 h (P = 0.002). This was explained by a low arterial pH but not by differences in gpH or prCO(2). CONCLUSION In acute respiratory and circulatory failure, H(2) blockade has an inconsistent impact on gpH and does not reduce variabilities of gpH or prCO(2).
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Affiliation(s)
- S M Jakob
- Department of of Anaesthesiology and Intensive Care Medicine, Kuopio University Hospital, Kuopio, Switzerland.
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Grogan EL, Norris PR, Speroff T, Ozdas A, France DJ, Harris PA, Jenkins JM, Stiles R, Dittus RS, Morris JA. Volatility: A New Vital Sign Identified Using a Novel Bedside Monitoring Strategy. ACTA ACUST UNITED AC 2005; 58:7-12; discussion 12-4. [PMID: 15674143 DOI: 10.1097/01.ta.0000151179.74839.98] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND SIMON (Signal Interpretation and Monitoring) monitors and archives continuous physiologic data in the ICU (HR, BP, CPP, ICP, CI, EDVI, SVO2, SPO2, SVRI, PAP, and CVP). We hypothesized: heart rate (HR) volatility predicts outcome better than measures of central tendency (mean and median). METHODS More than 600 million physiologic data points were archived from 923 patients over 2 years in a level one trauma center. Data were collected every 1 to 4 seconds, stored in a MS-SQL 7.0 relational database, linked to TRACS, and de-identified. Age, gender, race, Injury Severity Score (ISS), and HR statistics were analyzed with respect to outcome (death and ventilator days) using logistic and Poisson regression. RESULTS We analyzed 85 million HR data points, which represent more than 71,000 hours of continuous data capture. Mean HR varied by age, gender and ISS, but did not correlate with death or ventilator days. Measures of volatility (SD, % HR >120) correlated with death and prolonged ventilation. CONCLUSIONS 1) Volatility predicts death better than measures of central tendency. 2) Volatility is a new vital sign that we will apply to other physiologic parameters, and that can only be fully explored using techniques of dense data capture like SIMON. 3) Densely sampled aggregated physiologic data may identify sub-groups of patients requiring new treatment strategies.
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Affiliation(s)
- Eric L Grogan
- VA Quality Scholars Program, Vanderbilt University Department of Surgery, Nashville, Tennessee, USA
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van de Borne P. Variability science in intensive care - how relevant is it? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:414-5. [PMID: 15566604 PMCID: PMC1065051 DOI: 10.1186/cc2938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The article by Seely et al. in this issue of Critical Care highlights that variability portend prognosis. Numerous parameters interact to modify variability in intensive care. The commentary discusses why variability can nevertheless accurately estimate prognosis and how easily this can be implemented in the critically ill.
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Affiliation(s)
- P van de Borne
- Department of Cardiology, Erasme Hospital, Brussels, Belgium.
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