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Appavu B, Temkit M'H, Foldes S, Burrows BT, Kuwabara M, Jacobson A, Adelson PD. Association of Outcomes with Model-Based Indices of Cerebral Autoregulation After Pediatric Traumatic Brain Injury. Neurocrit Care 2021; 35:640-650. [PMID: 34268644 DOI: 10.1007/s12028-021-01279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We investigated whether model-based indices of cerebral autoregulation (CA) are associated with outcomes after pediatric traumatic brain injury. METHODS This was a retrospective analysis of a prospective clinical database of 56 pediatric patients with traumatic brain injury undergoing intracranial pressure monitoring. CA indices were calculated, including pressure reactivity index (PRx), wavelet pressure reactivity index (wPRx), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Each CA index was used to compute optimal cerebral perfusion pressure (CPP). Time of CPP below lower limit of autoregulation (LLA) or above upper limit of autoregulation (ULA) were computed for each index. Demographic, physiologic, and neuroimaging data were collected. Primary outcome was determined using Pediatric Glasgow Outcome Scale Extended (GOSE-Peds) at 12 months, with higher scores being suggestive of unfavorable outcome. Univariate and multiple linear regression with guided stepwise variable selection was used to find combinations of risk factors that can best explain the variability of GOSE-Peds scores, and the best fit model was applied to the age strata. We hypothesized that higher GOSE-Peds scores were associated with higher CA values and more time below LLA or above ULA for each index. RESULTS At the univariate level, CPP, dose of intracranial hypertension, PRx, PAx, wPRx, RAC, percent time more than ULA derived for PAx, and percent time less than LLA derived for PRx, PAx, wPRx, and RAC were all associated with GOSE-Peds scores. The best subset model selection on all pediatric patients identified that when accounting for CPP, increased dose of intracranial hypertension and percent time less than LLA derived for wPRx were independently associated with higher GOSE-Peds scores. Age stratification of the best fit model identified that in children less than 2 years of age or 8 years of age or more, percent time less than LLA derived for wPRx represented the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and dose of intracranial hypertension. For children 2 years or younger to less than 8 years of age, dose of intracranial hypertension was identified as the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and percent time less than LLA derived for wPRx. CONCLUSIONS Increased dose of intracranial hypertension, PRx, wPRx, PAx, and RAC values and increased percentage time less than LLA based on PRx, wPRx, PAx, and RAC are associated with higher GOSE-Peds scores, suggestive of unfavorable outcome. Reducing intracranial hypertension and maintaining CPP more than LLA based on wPRx may improve outcomes and warrants prospective investigation.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.
| | - M 'Hamed Temkit
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Michael Kuwabara
- Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.,Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - P David Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
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Abstract
Carbon dioxide is a common gas in the air which has been widely used in medical treatment. A carbon dioxide molecule consists of two oxygen atoms and one carbon atom through a covalent bond. In the body, carbon dioxide reacts with water to produce carbonic acid. In healthy people, carbon dioxide is maintained within a narrow range (35–45 mmHg) by physiological mechanisms. The role of hypocapnia (partial pressure of carbon dioxide < 35 mmHg) and hypercapnia (partial pressure of carbon dioxide > 45 mmHg) in the nervous system is intricate. Past researches mainly focus on the effect of hypocapnia to nerve protection. Nevertheless, Hypercapnia seems to play an important role in neuroprotection. The mechanisms of hypocapnia and hypercapnia in the nervous system deserve our attention. The purpose of this review is to summarize the effect of hypocapnia and hypercapnia in stroke and traumatic brain injury.
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Affiliation(s)
- Ru-Ming Deng
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yong-Chun Liu
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jin-Quan Li
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jian-Guo Xu
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Wolf MS, Rakkar J, Horvat CM, Simon DW, Kochanek PM, Clermont G, Clark RSB. Assessment of Dynamic Intracranial Compliance in Children with Severe Traumatic Brain Injury: Proof-of-Concept. Neurocrit Care 2020; 34:209-217. [PMID: 32556856 PMCID: PMC7299131 DOI: 10.1007/s12028-020-01004-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background and Aims Intracranial compliance refers to the relationship between a change in intracranial volume and the resultant change in intracranial pressure (ICP). Measurement of compliance is useful in managing cardiovascular and respiratory failure; however, there are no contemporary means to assess intracranial compliance. Knowledge of intracranial compliance could complement ICP and cerebral perfusion pressure (CPP) monitoring in patients with severe traumatic brain injury (TBI) and may enable a proactive approach to ICP management. In this proof-of-concept study, we aimed to capitalize on the physiologic principles of intracranial compliance and vascular reactivity to CO2, and standard-of-care neurocritical care monitoring, to develop a method to assess dynamic intracranial compliance. Methods Continuous ICP and end-tidal CO2 (ETCO2) data from children with severe TBI were collected after obtaining informed consent in this Institutional Review Board-approved study. An intracranial pressure-PCO2 Compliance Index (PCI) was derived by calculating the moment-to-moment correlation between change in ICP and change in ETCO2. As such, “good” compliance may be reflected by a lack of correlation between time-synched changes in ICP in response to changes in ETCO2, and “poor” compliance may be reflected by a positive correlation between changes in ICP in response to changes in ETCO2. Results A total of 978 h of ICP and ETCO2 data were collected and analyzed from eight patients with severe TBI. Demographic and clinical characteristics included patient age 7.1 ± 5.8 years (mean ± SD); 6/8 male; initial Glasgow Coma Scale score 3 [3–7] (median [IQR]); 6/8 had decompressive surgery; 7.1 ± 1.4 ICP monitor days; ICU length of stay (LOS) 16.1 ± 6.8 days; hospital LOS 25.9 ± 8.4 days; and survival 100%. The mean PCI for all patients throughout the monitoring period was 0.18 ± 0.04, where mean ICP was 13.7 ± 2.1 mmHg. In this cohort, PCI was observed to be consistently above 0.18 by 12 h after monitor placement. Percent time spent with PCI thresholds > 0.1, 0.2, and 0.3 were 62% [24], 38% [14], and 23% [15], respectively. The percentage of time spent with an ICP threshold > 20 mmHg was 5.1% [14.6]. Conclusions Indirect assessment of dynamic intracranial compliance in TBI patients using standard-of-care monitoring appears feasible and suggests a prolonged period of derangement out to 5 days post-injury. Further study is ongoing to determine if the PCI—a new physiologic index, complements utility of ICP and/or CPP in guiding management of patients with severe TBI. Electronic supplementary material The online version of this article (10.1007/s12028-020-01004-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael S Wolf
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, Division of Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Jaskaran Rakkar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher M Horvat
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Dennis W Simon
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Robert S B Clark
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Faculty Pavilion, Suite 2000, Brain Care Institute, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
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Bajpai BK, Preiksaitis A, Vosylius S, Rocka S. Association Between the Cerebral Autoregulation Index (Pressure Reactivity), Patient's Clinical Outcome, and Quality of ABP(t) and ICP(t) Signals for CA Monitoring. MEDICINA-LITHUANIA 2020; 56:medicina56030143. [PMID: 32245122 PMCID: PMC7143400 DOI: 10.3390/medicina56030143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The aim of this study was to explore the association between the cerebral autoregulation (CA) index, the pressure reactivity index (PRx), the patient’s clinical outcome, and the quality of arterial blood pressure (ABP(t)) and intracranial blood pressure (ICP(t)) signals by comparing two filtering methods to derive the PRx. Materials and Methods: Data from 60 traumatic brain injury (TBI) patients were collected. Moving averaging and FIR (Finite Impulse Response) filtering were performed on the ABP(t) and ICP(t) signals, and the PRx was estimated from both filtered datasets. Sensitivity, specificity, and receiver-operating characteristic (ROC) curves with the area under the curves (AUCs) were determined using patient outcomes as a reference. The outcome chosen for comparison among the two filtering methods were mortality and survival. Results: The FIR filtering approach, compared with clinical outcome, had a sensitivity of 70%, a specificity of 81%, and a level of significance p = 0.001 with an area under the curve (AUC) of 0.78. The moving average filtering method compared with the clinical outcome had a sensitivity of 58%, a specificity of 72%, and a level of significance p = 0.054, with an area under the curve (AUC) of 0.66. Conclusions: The FIR (optimal) filtering approach was found to be more sensitive for discriminating between two clinical outcomes, namely intact (survival) and impaired (death) cerebral autoregulation for TBI treatment decision making.
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Affiliation(s)
- Basant K. Bajpai
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
- Correspondence: ; Tel.: +37064783364
| | - Aidanas Preiksaitis
- Centre of Neurosurgery, Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, LT08661 Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Anesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT08661 Vilnius, Lithuania
| | - Saulius Rocka
- Centre of Neurosurgery, Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, LT08661 Vilnius, Lithuania
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