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Meng L, Sun Y, Zhao X, Rasmussen M, Al-Tarshan Y, Meng DM, Liu Z, Adams DC, McDonagh DL. Noradrenaline-induced changes in cerebral blood flow in health, traumatic brain injury and critical illness: a systematic review with meta-analysis. Anaesthesia 2024. [PMID: 38831595 DOI: 10.1111/anae.16313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Noradrenaline is a standard treatment for hypotension in acute care. The precise effects of noradrenaline on cerebral blood flow in health and disease remain unclear. METHODS We systematically reviewed and synthesised data from studies examining changes in cerebral blood flow in healthy participants and patients with traumatic brain injury and critical illness. RESULTS Twenty-eight eligible studies were included. In healthy subjects and patients without critical illness or traumatic brain injury, noradrenaline did not significantly change cerebral blood flow velocity (-1.7%, 95%CI -4.7-1.3%) despite a 24.1% (95%CI 19.4-28.7%) increase in mean arterial pressure. In patients with traumatic brain injury, noradrenaline significantly increased cerebral blood flow velocity (21.5%, 95%CI 11.0-32.0%), along with a 33.8% (95%CI 14.7-52.9%) increase in mean arterial pressure. In patients who were critically ill, noradrenaline significantly increased cerebral blood flow velocity (20.0%, 95%CI 9.7-30.3%), along with a 32.4% (95%CI 25.0-39.9%) increase in mean arterial pressure. Our analyses suggest intact cerebral autoregulation in healthy subjects and patients without critical illness or traumatic brain injury., and impaired cerebral autoregulation in patients with traumatic brain injury and who were critically ill. The extent of mean arterial pressure changes and the pre-treatment blood pressure levels may affect the magnitude of cerebral blood flow changes. Studies assessing cerebral blood flow using non-transcranial Doppler methods were inadequate and heterogeneous in enabling meaningful meta-analysis. CONCLUSIONS Noradrenaline significantly increases cerebral blood flow in humans with impaired, not intact, cerebral autoregulation, with the extent of changes related to the severity of functional impairment, the extent of mean arterial pressure changes and pre-treatment blood pressure levels.
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Affiliation(s)
- Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mads Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | | | - Deyi M Meng
- Choate Rosemary Hall School, Wallingford, CT, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, Neurology, UT Southwestern Medical Center, Dallas, TX, USA
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Birnefeld J, Petersson K, Wåhlin A, Eklund A, Birnefeld E, Qvarlander S, Haney M, Malm J, Zarrinkoob L. Cerebral Blood Flow Assessed with Phase-contrast Magnetic Resonance Imaging during Blood Pressure Changes with Noradrenaline and Labetalol: A Trial in Healthy Volunteers. Anesthesiology 2024; 140:669-678. [PMID: 37756527 DOI: 10.1097/aln.0000000000004775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND Adequate cerebral perfusion is central during general anesthesia. However, perfusion is not readily measured bedside. Clinicians currently rely mainly on mean arterial pressure (MAP) as a surrogate, even though the relationship between blood pressure and cerebral blood flow is not well understood. The aim of this study was to apply phase-contrast magnetic resonance imaging to characterize blood flow responses in healthy volunteers to commonly used pharmacologic agents that increase or decrease arterial blood pressure. METHODS Eighteen healthy volunteers aged 30 to 50 yr were investigated with phase-contrast magnetic resonance imaging. Intra-arterial blood pressure monitoring was used. First, intravenous noradrenaline was administered to a target MAP of 20% above baseline. After a wash-out period, intravenous labetalol was given to a target MAP of 15% below baseline. Cerebral blood flow was measured using phase-contrast magnetic resonance imaging and defined as the sum of flow in the internal carotid arteries and vertebral arteries. Cardiac output (CO) was defined as the flow in the ascending aorta. RESULTS Baseline median cerebral blood flow was 772 ml/min (interquartile range, 674 to 871), and CO was 5,874 ml/min (5,199 to 6,355). The median dose of noradrenaline was 0.17 µg · kg-1 · h-1 (0.14 to 0.22). During noradrenaline infusion, cerebral blood flow decreased to 705 ml/min (606 to 748; P = 0.001), and CO decreased to 4,995 ml/min (4,705 to 5,635; P = 0.01). A median dose of labetalol was 120 mg (118 to 150). After labetalol boluses, cerebral blood flow was unchanged at 769 ml/min (734 to 900; P = 0.68). CO increased to 6,413 ml/min (6,056 to 7,464; P = 0.03). CONCLUSIONS In healthy, awake subjects, increasing MAP using intravenous noradrenaline decreased cerebral blood flow and CO. These data do not support inducing hypertension with noradrenaline to increase cerebral blood flow. Cerebral blood flow was unchanged when decreasing MAP using labetalol. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Johan Birnefeld
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
| | - Karl Petersson
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Unit, Umeå University, Umeå, Sweden
| | - Anders Wåhlin
- Departments of Radiation Sciences, Biomedical Engineering and Applied Physics and Electronics and Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Departments of Radiation Sciences, Biomedical Engineering and Applied Physics and Electronics, Umeå University, Umeå, Sweden
| | - Elin Birnefeld
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Unit, Umeå University, Umeå, Sweden
| | - Sara Qvarlander
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Michael Haney
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Unit, Umeå University, Umeå, Sweden
| | - Jan Malm
- Department of Clinical Sciences, Neurosciences, Umeå University, Umeå, Sweden
| | - Laleh Zarrinkoob
- Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine Unit, Umeå University, Umeå, Sweden
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Yu J, Park JY, Hong JH, Hwang JH, Kim YK. Effect of pneumoperitoneum and Trendelenburg position on internal carotid artery blood flow measured by ultrasound during robotic prostatectomy. Clin Physiol Funct Imaging 2022; 42:139-145. [PMID: 35018713 DOI: 10.1111/cpf.12742] [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: 11/01/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy. METHODS Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point. RESULTS A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3±44.7 [T2] vs. 188.0±49.6 mL/min [T1], P=0.002; 163.1±39.9 [T3] vs. 188.0±49.6 mL/min [T1], P=0.009). The ICA blood flow also differed significantly between Ta and T1 (236.8±58.3 vs. 188.0±49.6 mL/min, P<0.001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points. CONCLUSION Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Glumac S, Kardum G, Sodic L, Bulat C, Covic I, Carev M, Karanovic N. Longitudinal assessment of preoperative dexamethasone administration on cognitive function after cardiac surgery: a 4-year follow-up of a randomized controlled trial. BMC Anesthesiol 2021; 21:129. [PMID: 33892653 PMCID: PMC8063389 DOI: 10.1186/s12871-021-01348-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 04/16/2021] [Indexed: 01/13/2023] Open
Abstract
Background The pathogenesis of postoperative cognitive decline (POCD) is still poorly understood; however, the inflammatory response to surgical procedures seems likely to be involved. In addition, our recent randomized controlled trial showed that perioperative corticosteroid treatment may ameliorate early POCD after cardiac surgery. To assess the long-term effect of dexamethasone administration on cognitive function, we conducted a 4-year follow-up. Methods The patients were randomized to receive a single intravenous bolus of 0.1 mg kg− 1 dexamethasone or placebo 10 h before elective cardiac surgery. The endpoint in both groups was POCD incidence on the 6th day and four years postoperatively. Results Of the 161 patients analyzed previously, the current follow-up included 116 patients. Compared to the 62 patients in the placebo group, the 54 patients in the dexamethasone group showed a lower incidence of POCD on the 6th day (relative risk (RR), 0.510; 95 % confidence interval (CI), 0.241 to 1.079; p = 0.067, time interval also analyzed previously) and four years (RR, 0.459; 95 % CI, 0.192 to 1.100; p = 0.068) after cardiac surgery. The change in cognitive status between the two postoperative measurements was not significant (p = 0.010) among the patients in the dexamethasone group, in contrast to patients in the placebo group (p = 0.673). Conclusions Although statistical significance was not reached in the current study, the prophylactic administration of dexamethasone seems to be useful to prevent POCD development following cardiac surgery. However, further large multicenter research is needed to confirm these directions. Trial registration ClinicalTrials.gov identifier: NCT02767713 (10/05/2016). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01348-z.
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Affiliation(s)
- Sandro Glumac
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Spinciceva 1, 21000, Split, Croatia.
| | - Goran Kardum
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
| | - Lidija Sodic
- Department of Neurology, University Hospital of Split, Split, Croatia
| | - Cristijan Bulat
- Department of Cardiac Surgery, University Hospital of Split, Split, Croatia
| | - Ivan Covic
- School of Medicine, University of Split, Split, Croatia
| | - Mladen Carev
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Spinciceva 1, 21000, Split, Croatia.,Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
| | - Nenad Karanovic
- Department of Anesthesiology and Intensive Care, University Hospital of Split, Spinciceva 1, 21000, Split, Croatia.,Department of Anesthesiology and Intensive Medicine, School of Medicine, University of Split, Split, Croatia
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Møller A, Wetterslev J, Shahidi S, Hellemann D, Secher NH, Pedersen OB, Marcussen KV, Ramsing BGU, Mortensen A, Nielsen HB. Effect of low vs high haemoglobin transfusion trigger on cardiac output in patients undergoing elective vascular surgery: Post-hoc analysis of a randomized trial. Acta Anaesthesiol Scand 2021; 65:302-312. [PMID: 33141936 DOI: 10.1111/aas.13733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND During vascular surgery, restricted red-cell transfusion reduces frontal lobe oxygen (ScO2 ) saturation as determined by near-infrared spectroscopy. We evaluated whether inadequate increase in cardiac output (CO) following haemodilution explains reduction in ScO2 . METHODS This is a post-hoc analysis of data from the Transfusion in Vascular surgery (TV) Trial where patients were randomized on haemoglobin drop below 9.7 g/dL to red-cell transfusion at haemoglobin below 8.0 (low-trigger) vs 9.7 g/dL (high-trigger). Fluid administration was guided by optimizing stroke volume. We compared mean intraoperative levels of CO, haemoglobin, oxygen delivery, and CO at nadir ScO2 with linear regression adjusted for age, operation type and baseline. Data for 46 patients randomized before end of surgery were included for analysis. RESULTS The low-trigger resulted in a 7.1% lower mean intraoperative haemoglobin level (mean difference, -0.74 g/dL; P < .001) and reduced volume of red-cell transfused (median [inter-quartile range], 0 [0-300] vs 450 mL [300-675]; P < .001) compared with the high-trigger group. Mean CO during surgery was numerically 7.3% higher in the low-trigger compared with the high-trigger group (mean difference, 0.36 L/min; 95% confidence interval (CI.95), -0.05 to 0.78; P = .092; n = 42). At the nadir ScO2 -level, CO was 11.9% higher in the low-trigger group (mean difference, 0.58 L/min; CI.95, 0.10-1.07; P = .024). No difference in oxygen delivery was detected between trial groups (MD, 1.39 dLO2 /min; CI.95, -6.16 to 8.93; P = .721). CONCLUSION Vascular surgical patients exposed to restrictive RBC transfusion elicit the expected increase in CO making it unlikely that their potentially limited cardiac capacity explains the associated ScO2 decrease.
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Affiliation(s)
- Anders Møller
- Department of Anaesthesia and Intensive care Næstved‐Slagelse‐Ringsted Slagelse Hospital Slagelse Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit Centre for Clinical Intervention Research, Rigshospitalet Copenhagen Denmark
| | - Saeid Shahidi
- Department of Cardiology and Vascular Surgery Zealand University Hospital Roskilde Roskilde Denmark
| | - Dorthe Hellemann
- Department of Anaesthesia and Intensive care Næstved‐Slagelse‐Ringsted Slagelse Hospital Slagelse Denmark
| | - Niels H. Secher
- Department of Anaesthesia, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Ole B. Pedersen
- Department of Clinical Immunology Næstved Hospital Nastved Denmark
| | - Klaus V. Marcussen
- Department of Anaesthesia and Intensive care Næstved‐Slagelse‐Ringsted Slagelse Hospital Slagelse Denmark
| | - Benedicte G. U. Ramsing
- Department of Anaesthesia and Intensive care Næstved‐Slagelse‐Ringsted Slagelse Hospital Slagelse Denmark
| | - Anette Mortensen
- Department of Anaesthesia and Intensive care Næstved‐Slagelse‐Ringsted Slagelse Hospital Slagelse Denmark
| | - Henning B. Nielsen
- Department of Anaesthesia Zealand University Hospital Roskilde Roskilde Denmark
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Sørensen H. Is cerebral monitoring useful? Focus must shift from mere observation to testing interventions. Acta Anaesthesiol Scand 2020; 64:568-569. [PMID: 32058601 DOI: 10.1111/aas.13562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/11/2020] [Accepted: 02/11/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Henrik Sørensen
- Department of Anaesthesia, Centre for Cancer and Organ Diseases, Copenhagen, Denmark.,Department of Integrative Physiology, NEXS, University of Copenhagen, Copenhagen, Denmark
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