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Hencz AJ, Magony A, Thomas C, Kovacs K, Szilagyi G, Pal J, Sik A. Short-term hyperoxia-induced functional and morphological changes in rat hippocampus. Front Cell Neurosci 2024; 18:1376577. [PMID: 38686017 PMCID: PMC11057248 DOI: 10.3389/fncel.2024.1376577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Excess oxygen (O2) levels may have a stimulating effect, but in the long term, and at high concentrations of O2, it is harmful to the nervous system. The hippocampus is very sensitive to pathophysiological changes and altered O2 concentrations can interfere with hippocampus-dependent learning and memory functions. In this study, we investigated the hyperoxia-induced changes in the rat hippocampus to evaluate the short-term effect of mild and severe hyperoxia. Wistar male rats were randomly divided into control (21% O2), mild hyperoxia (30% O2), and severe hyperoxia groups (100% O2). The O2 exposure lasted for 60 min. Multi-channel silicon probes were used to study network oscillations and firing properties of hippocampal putative inhibitory and excitatory neurons. Neural damage was assessed using the Gallyas silver impregnation method. Mild hyperoxia (30% O2) led to the formation of moderate numbers of silver-impregnated "dark" neurons in the hippocampus. On the other hand, exposure to 100% O2 was associated with a significant increase in the number of "dark" neurons located mostly in the hilus. The peak frequency of the delta oscillation decreased significantly in both mild and severe hyperoxia in urethane anesthetized rats. Compared to normoxia, the firing activity of pyramidal neurons under hyperoxia increased while it was more heterogeneous in putative interneurons in the cornu ammonis area 1 (CA1) and area 3 (CA3). These results indicate that short-term hyperoxia can change the firing properties of hippocampal neurons and network oscillations and damage neurons. Therefore, the use of elevated O2 concentration inhalation in hospitals (i.e., COVID treatment and surgery) and in various non-medical scenarios (i.e., airplane emergency O2 masks, fire-fighters, and high altitude trekkers) must be used with extreme caution.
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Affiliation(s)
| | - Andor Magony
- Institute of Physiology, Medical School, University of Pécs, Pécs, Hungary
| | - Chloe Thomas
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Krisztina Kovacs
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Gabor Szilagyi
- Institute of Biochemistry and Medical Chemistry, Medical School, University of Pécs, Pécs, Hungary
| | - Jozsef Pal
- Institute of Physiology, Medical School, University of Pécs, Pécs, Hungary
| | - Attila Sik
- Institute of Physiology, Medical School, University of Pécs, Pécs, Hungary
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Rakkar J, Azar J, Pelletier JH, Au AK, Bell MJ, Simon DW, Kochanek PM, Clark RSB, Horvat CM. Temporal Patterns in Brain Tissue and Systemic Oxygenation Associated with Mortality After Severe Traumatic Brain Injury in Children. Neurocrit Care 2023; 38:71-84. [PMID: 36171518 PMCID: PMC9957965 DOI: 10.1007/s12028-022-01602-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/30/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Brain tissue hypoxia is an independent risk factor for unfavorable outcomes in traumatic brain injury (TBI); however, systemic hyperoxemia encountered in the prevention and/or response to brain tissue hypoxia may also impact risk of mortality. We aimed to identify temporal patterns of partial pressure of oxygen in brain tissue (PbtO2), partial pressure of arterial oxygen (PaO2), and PbtO2/PaO2 ratio associated with mortality in children with severe TBI. METHODS Data were extracted from the electronic medical record of a quaternary care children's hospital with a level I trauma center for patients ≤ 18 years old with severe TBI and the presence of PbtO2 and/or intracranial pressure monitors. Temporal analyses were performed for the first 5 days of hospitalization by using locally estimated scatterplot smoothing for less than 1,000 observations and generalized additive models with integrated smoothness estimation for more than 1,000 observations. RESULTS A total of 138 intracranial pressure-monitored patients with TBI (median 5.0 [1.9-12.8] years; 65% boys; admission Glasgow Coma Scale score 4 [3-7]; mortality 18%), 71 with PbtO2 monitors and 67 without PbtO2 monitors were included. Distinct patterns in PbtO2, PaO2, and PbtO2/PaO2 were evident between survivors and nonsurvivors over the first 5 days of hospitalization. Time-series analyses showed lower PbtO2 values on day 1 and days 3-5 and lower PbtO2/PaO2 ratios on days 1, 2, and 5 among patients who died. Analysis of receiver operating characteristics curves using Youden's index identified a PbtO2 of 30 mm Hg and a PbtO2/PaO2 ratio of 0.12 as the cut points for discriminating between survivors and nonsurvivors. Univariate logistic regression identified PbtO2 < 30 mm Hg, hyperoxemia (PaO2 ≥ 300 mm Hg), and PbtO2/PaO2 ratio < 0.12 to be independently associated with mortality. CONCLUSIONS Lower PbtO2, higher PaO2, and lower PbtO2/PaO2 ratio, consistent with impaired oxygen diffusion into brain tissue, were associated with mortality in this cohort of children with severe TBI. These results corroborate our prior work that suggests targeting a higher PbtO2 threshold than recommended in current guidelines and highlight the potential use of the PbtO2/PaO2 ratio in the management of severe pediatric TBI.
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Affiliation(s)
- Jaskaran Rakkar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Azar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pediatric Critical Care, Geisinger Medical Center, Danville, PA, USA
| | - Jonathan H Pelletier
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alicia K Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Asehnoune K, Taccone FS, Singer M. High oxygen level in traumatic brain injury patients. Never ending story? Intensive Care Med 2022; 48:1772-1774. [PMID: 36264364 DOI: 10.1007/s00134-022-06903-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/28/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.
- Head, Anaesthesia and Surgical Critical Care Department, University Hospital of Nantes, Hôtel Dieu, 44000, Nantes, France.
- Lab Inserm, UMR 1064 CR2TI | Team 6, Nantes, France.
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mervyn Singer
- Mervyn Singer, Bloomsbury Institute of Intensive Care, University College London, London, UK
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The Impact of Invasive Brain Oxygen Pressure Guided Therapy on the Outcome of Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:779-789. [PMID: 36180764 DOI: 10.1007/s12028-022-01613-0] [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: 06/10/2022] [Accepted: 09/16/2022] [Indexed: 11/25/2022]
Abstract
Traumatic brain injury (TBI) is a major public health burden, causing death and disability worldwide. Intracranial hypertension and brain hypoxia are the main mechanisms of secondary brain injury. As such, management strategies guided by intracranial pressure (ICP) and brain oxygen (PbtO2) monitoring could improve the prognosis of these patients. Our objective was to summarize the current evidence regarding the impact of PbtO2-guided therapy on the outcome of patients with TBI. We performed a systematic search of PubMed, Scopus, and the Cochrane library databases, following the protocol registered in PROSPERO. Only studies comparing PbtO2/ICP-guided therapy with ICP-guided therapy were selected. Primary outcome was neurological outcome at 3 and 6 months assessed by using the Glasgow Outcome Scale; secondary outcomes included hospital and long-term mortality, burden of intracranial hypertension, and brain tissue hypoxia. Out of 6254 retrieved studies, 15 studies (n = 37,245 patients, of who 2184 received PbtO2-guided therapy) were included in the final analysis. When compared with ICP-guided therapy, the use of combined PbO2/ICP-guided therapy was associated with a higher probability of favorable neurological outcome (odds ratio 2.21 [95% confidence interval 1.72-2.84]) and of hospital survival (odds ratio 1.15 [95% confidence interval 1.04-1.28]). The heterogeneity (I2) of the studies in each analysis was below 40%. However, the quality of evidence was overall low to moderate. In this meta-analysis, PbtO2-guided therapy was associated with reduced mortality and more favorable neurological outcome in patients with TBI. The low-quality evidence underlines the need for the results from ongoing phase III randomized trials.
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Brain tissue oxygen tension: Is it a derivative of arterial blood? Crit Care 2022; 26:286. [PMID: 36151548 PMCID: PMC9508714 DOI: 10.1186/s13054-022-04130-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/20/2022] [Indexed: 11/21/2022] Open
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Giannì G, Taccone FS, Bogossian EG. The Impact of Short-Term Normobaric Hyperoxia on Brain Metabolism: A Pilot Microdialysis Study. Neurocrit Care 2022; 37:770-774. [PMID: 35773602 DOI: 10.1007/s12028-022-01557-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Giuseppina Giannì
- Department of Intensive Care, Erasme Hospital and Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital and Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Erasme Hospital and Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
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The Impact of Short-Term Hyperoxia on Cerebral Metabolism: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:547-557. [PMID: 35641804 DOI: 10.1007/s12028-022-01529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cerebral ischemia due to hypoxia is a major cause of secondary brain injury and is associated with higher morbidity and mortality in patients with acute brain injury. Hyperoxia could improve energetic dysfunction in the brain in this setting. Our objectives were to perform a systematic review and meta-analysis of the current literature and to assess the impact of normobaric hyperoxia on brain metabolism by using cerebral microdialysis. METHODS We searched Medline and Scopus, following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement; we searched for retrospective and prospective observational studies, interventional studies, and randomized clinical trials that performed a hyperoxia challenge in patients with acute brain injury who were concomitantly monitored with cerebral microdialysis. This study was registered in PROSPERO (CRD420211295223). RESULTS We included a total of 17 studies, with a total of 311 patients. A statistically significant reduction in cerebral lactate values (pooled standardized mean difference [SMD] - 0.38 [- 0.53 to - 0.23]) and lactate to pyruvate ratio values (pooled SMD - 0.20 [- 0.35 to - 0.05]) was observed after hyperoxia. However, glucose levels (pooled SMD - 0.08 [- 0.23 to 0.08]) remained unchanged after hyperoxia. CONCLUSIONS Normobaric hyperoxia may improve cerebral metabolic disturbances in patients with acute brain injury. The clinical impact of such effects needs to be further elucidated.
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Cialoni D, Brizzolari A, Samaja M, Bosco G, Paganini M, Sponsiello N, Lancellotti V, Marroni A. Endothelial Nitric Oxide Production and Antioxidant Response in Breath-Hold Diving: Genetic Predisposition or Environment Related? Front Physiol 2021; 12:692204. [PMID: 34305646 PMCID: PMC8300565 DOI: 10.3389/fphys.2021.692204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/08/2021] [Indexed: 12/21/2022] Open
Abstract
Introduction Nitric oxide (NO) is an essential signaling molecule modulating the endothelial adaptation during breath-hold diving (BH-diving). This study aimed to investigate changes in NO derivatives (NOx) and total antioxidant capacity (TAC), searching for correlations with different environmental and hyperbaric exposure. Materials and methods Blood samples were obtained from 50 breath-hold divers (BH-divers) before, and 30 and 60 min after the end of training sessions performed both in a swimming pool or the sea. Samples were tested for NOx and TAC differences in different groups related to their hyperbaric exposure, experience, and additional genetic polymorphism. Results We found statistically significant differences in NOx plasma concentration during the follow-up (decrease at T30 and increase at T60) compared with the pre-dive values. At T30, we found a significantly lower decrease of NOx in subjects with a higher diving experience, but no difference was detected between the swimming pool and Sea. No significant difference was found in TAC levels, as well as between NOx and TAC levels and the genetic variants. Conclusion These data showed how NO consumption in BH-diving is significantly lower in the expert group, indicating a possible training-related adaptation process. Data confirm a significant NO use during BH-diving, compatible with the well-known BH-diving related circulatory adaptation suggesting that the reduction in NOx 30 min after diving can be ascribed to the lower NO availability in the first few minutes after the dives. Expert BH-divers suffered higher oxidative stress. A preliminary genetic investigation seems to indicate a less significant influence of genetic predisposition.
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Affiliation(s)
- Danilo Cialoni
- Environmental Physiology and Medicine Laboratory, Department of Biomedical Sciences, Università degli Studi di Padova, Padua, Italy.,DAN Europe Research Division, DAN Europe Foundation, Roseto degli Abruzzi, Italy.,Apnea Academy Research, Padua, Italy
| | - Andrea Brizzolari
- DAN Europe Research Division, DAN Europe Foundation, Roseto degli Abruzzi, Italy.,Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Michele Samaja
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Gerardo Bosco
- Environmental Physiology and Medicine Laboratory, Department of Biomedical Sciences, Università degli Studi di Padova, Padua, Italy
| | - Matteo Paganini
- Environmental Physiology and Medicine Laboratory, Department of Biomedical Sciences, Università degli Studi di Padova, Padua, Italy
| | | | - Valentina Lancellotti
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Alessandro Marroni
- DAN Europe Research Division, DAN Europe Foundation, Roseto degli Abruzzi, Italy
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Yamamoto R, Fujishima S, Sasaki J, Gando S, Saitoh D, Shiraishi A, Kushimoto S, Ogura H, Abe T, Mayumi T, Kotani J, Nakada TA, Shiino Y, Tarui T, Okamoto K, Sakamoto Y, Shiraishi SI, Takuma K, Tsuruta R, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Hifumi T, Yamakawa K, Hagiwara A, Otomo Y. Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis. World J Emerg Surg 2021; 16:19. [PMID: 33926507 PMCID: PMC8082221 DOI: 10.1186/s13017-021-00363-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/16/2021] [Indexed: 12/28/2022] Open
Abstract
Background Information on hyperoxemia among patients with trauma has been limited, other than traumatic brain injuries. This study aimed to elucidate whether hyperoxemia during resuscitation of patients with trauma was associated with unfavorable outcomes. Methods A post hoc analysis of a prospective observational study was carried out at 39 tertiary hospitals in 2016–2018 in adult patients with trauma and injury severity score (ISS) of > 15. Hyperoxemia during resuscitation was defined as PaO2 of ≥ 300 mmHg on hospital arrival and/or 3 h after arrival. Intensive care unit (ICU)-free days were compared between patients with and without hyperoxemia. An inverse probability of treatment weighting (IPW) analysis was conducted to adjust patient characteristics including age, injury mechanism, comorbidities, vital signs on presentation, chest injury severity, and ISS. Analyses were stratified with intubation status at the emergency department (ED). The association between biomarkers and ICU length of stay were then analyzed with multivariate models. Results Among 295 severely injured trauma patients registered, 240 were eligible for analysis. Patients in the hyperoxemia group (n = 58) had shorter ICU-free days than those in the non-hyperoxemia group [17 (10–21) vs 23 (16–26), p < 0.001]. IPW analysis revealed the association between hyperoxemia and prolonged ICU stay among patients not intubated at the ED [ICU-free days = 16 (12–22) vs 23 (19–26), p = 0.004], but not among those intubated at the ED [18 (9–20) vs 15 (8–23), p = 0.777]. In the hyperoxemia group, high inflammatory markers such as soluble RAGE and HMGB-1, as well as low lung-protective proteins such as surfactant protein D and Clara cell secretory protein, were associated with prolonged ICU stay. Conclusions Hyperoxemia until 3 h after hospital arrival was associated with prolonged ICU stay among severely injured trauma patients not intubated at the ED. Trial registration UMIN-CTR, UMIN000019588. Registered on November 15, 2015. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00363-2.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Gando
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.,Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa, Japan
| | | | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu, Japan
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga, Japan
| | - Shin-Ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu, Japan
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki, Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube, Japan
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute, Japan
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center, Japan Community Healthcare Organization, Chukyo Hospital, Nagoya, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Akiyoshi Hagiwara
- Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
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Yamamoto R, Yoshizawa J. Oxygen administration in patients recovering from cardiac arrest: a narrative review. J Intensive Care 2020; 8:60. [PMID: 32832091 PMCID: PMC7419438 DOI: 10.1186/s40560-020-00477-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
High oxygen tension in blood and/or tissue affects clinical outcomes in several diseases. Thus, the optimal target PaO2 for patients recovering from cardiac arrest (CA) has been extensively examined. Many patients develop hypoxic brain injury after the return of spontaneous circulation (ROSC); this supports the need for oxygen administration in patients after CA. Insufficient oxygen delivery due to decreased blood flow to cerebral tissue during CA results in hypoxic brain injury. By contrast, hyperoxia may increase dissolved oxygen in the blood and, subsequently, generate reactive oxygen species that are harmful to neuronal cells. This secondary brain injury is particularly concerning. Although several clinical studies demonstrated that hyperoxia during post-CA care was associated with poor neurological outcomes, considerable debate is ongoing because of inconsistent results. Potential reasons for the conflicting results include differences in the definition of hyperoxia, the timing of exposure to hyperoxia, and PaO2 values used in analyses. Despite the conflicts, exposure to PaO2 > 300 mmHg through administration of unnecessary oxygen should be avoided because no obvious benefit has been demonstrated. The feasibility of titrating oxygen administration by targeting SpO2 at approximately 94% in patients recovering from CA has been demonstrated in pilot randomized controlled trials (RCTs). Such protocols should be further examined.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan
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Ketharanathan N, De Jonge RCJ, Klouwen I, Wildschut ED, Reiss IKM, Tibboel D, Haitsma IKM, Buysse CMP. Hyperoxia in pediatric severe traumatic brain injury (TBI): a comparison of patient classification by cutoff versus cumulative (area-under-the-curve) analysis. Brain Inj 2020; 34:958-964. [PMID: 32485120 DOI: 10.1080/02699052.2020.1765021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Hyperoxia is associated with adverse outcome in severe traumatic brain injury (TBI). This study explored differences in patient classification of oxygen exposure by PaO2 cutoff and cumulative area-under-the-curve (AUC) analysis. METHODS Retrospective, explorative study including children (<18 years) with accidental severe TBI (2002-2015). Oxygen exposure analysis used three PaO2 cutoff values and four PaO2 AUC categories during the first 24 hours of Pediatric Intensive Care Unit (PICU) admission. RESULTS Seventy-one patients were included (median age 8.9 years [IQR 4.6-12.9]), mortality 18.3% (n = 13). Patient hyperoxia classification differed depending on PaO2 cutoff vs AUC analysis: 52% vs. 26%, respectively, were classified in the highest hyperoxia category. Eleven patients (17%) classified as 'intermediate oxygen exposure' based on cumulative PaO2 analysis whereby they did not exceed the 200 mmHg PaO2 cutoff threshold. Patient classification variability was reflected by Pearson correlation coefficient of 0.40 (p-value 0.001). CONCLUSIONS Hyperoxia classification in pediatric severe TBI during the first 24 hours of PICU admission differed depending on PaO2 cutoff or cumulative AUC analysis. We consider PaO2 cumulative (AUC) better approximates (patho-)physiological circumstances due to its time- and dose-dependent approach. Prospective studies exploring the association between cumulative PaO2, physiological parameters (e.g. ICP, PbtO2) and outcome are warranted as different patient classifications of oxygen exposure influences how its relationship to outcome is interpreted.
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Affiliation(s)
- Naomi Ketharanathan
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Rogier C J De Jonge
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Ilse Klouwen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Enno D Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Iain K M Haitsma
- Department of Neurosurgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Corinne M P Buysse
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
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12
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Association between hyperoxemia and mortality in patients treated by eCPR after out-of-hospital cardiac arrest. Am J Emerg Med 2020; 38:900-905. [DOI: 10.1016/j.ajem.2019.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/26/2019] [Accepted: 07/06/2019] [Indexed: 01/08/2023] Open
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13
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Ottolenghi S, Rubino FM, Sabbatini G, Coppola S, Veronese A, Chiumello D, Paroni R. Oxidative Stress Markers to Investigate the Effects of Hyperoxia in Anesthesia. Int J Mol Sci 2019; 20:ijms20215492. [PMID: 31690051 PMCID: PMC6862279 DOI: 10.3390/ijms20215492] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022] Open
Abstract
Oxygen (O2) is commonly used in clinical practice to prevent or treat hypoxia, but if used in excess (hyperoxia), it may act as toxic. O2 toxicity arises from the enhanced formation of Reactive Oxygen Species (ROS) that exceed the antioxidant defenses and generate oxidative stress. In this study, we aimed at assessing whether an elevated fraction of inspired oxygen (FiO2) during and after general anesthesia may contribute to the unbalancing of the pro-oxidant/antioxidant equilibrium. We measured five oxidative stress biomarkers in blood samples from patients undergoing elective abdominal surgery, randomly assigned to FiO2 = 0.40 vs. 0.80: hydroperoxides, antioxidants, nitrates and nitrites (NOx), malondialdehyde (MDA), and glutathionyl hemoglobin (HbSSG). The MDA concentration was significantly higher 24 h after surgery, and the body antioxidant defense lower, in the FiO2 = 0.80 group with respect to both the FiO2 = 0.40 group and the baseline values (p ≤ 0.05, Student’s t-test). HbSSG in red blood cells was also higher in the FiO2 = 0.80 group at the end of the surgery. NOx was higher in the FiO2 = 0.80 group than the FiO2 = 0.40 group at t = 2 h after surgery. MDA, the main end product of the peroxidation of polyunsaturated fatty acids directly influenced by FiO2, may represent the best marker to assess the pro-oxidant/antioxidant equilibrium after surgery.
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Affiliation(s)
- Sara Ottolenghi
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
| | - Federico Maria Rubino
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
| | - Giovanni Sabbatini
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
| | - Alice Veronese
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
| | - Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
- Coordinated Research Center on Respiratory Failure, University of Milan, 20123 Milan, Italy.
| | - Rita Paroni
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
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14
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Ischemic Stroke in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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15
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Jouffroy R, Philippe P, Saade A, Carli P, Vivien B. Prognostic Value of Blood Lactate and Base Deficit in Refractory Cardiac Arrest Cases Undergoing Extracorporeal Life Support. Turk J Anaesthesiol Reanim 2019; 47:407-413. [PMID: 31572993 DOI: 10.5152/tjar.2019.65391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 09/26/2018] [Indexed: 12/23/2022] Open
Abstract
Objective Cardiac arrest (CA) resuscitation is associated with an 'ischaemia-reperfusion' syndrome characterised by lactic acidosis as assessed by lactate and base deficit (BD). Both biomarkers are usually measured in patients suffering from refractory CA (RCA) subjected to extracorporeal life support (ECLS) to evaluate tissue reperfusion. However, their prognostic value has never been compared. The aim of the present study was to compare the prognostic value of both biomarkers measured at 0 and 3 h after the initiation of ECLS in patients with RCA on mortality. Methods Patients who were admitted to the intensive care unit with RCA were consecutively included in the study. Results Sixty-six patients were included. Lactate correlated with BD (R2=0.44, p<0.001). An area under the curve of 0.72 (95% confidence interval (CI) 0.59-0.84) was found for lactate and of 0.60 (95% CI 0.46-0.73) for BD. Using multivariable logistic regression, lactate (odds ratio (OR) 1.22, 95% CI 1.03-1.48) remained associated with mortality on day 28, but not BD (OR 0.99, 95% CI 0.86-1.14). Conclusion We report a difference in the prognostic value of lactate and BD on mortality. Three hours from the initiation of ECLS in patients with RCA, lactate should be preferred to BD to predict the efficiency of ECLS.
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Affiliation(s)
- Romain Jouffroy
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Pascal Philippe
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Anastasia Saade
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Pierre Carli
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Benoit Vivien
- Departments of Anaesthesia and Intensive Care Unit, SAMU, Hôpital Universitaire Necker - Enfants Malades, Université Paris Descartes, Paris, France
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16
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Jeong E, Ryu H, Shin JH, Kwon GH, Jo G, Lee JY. High Oxygen Exchange to Music Indicates Auditory Distractibility in Acquired Brain Injury: An fNIRS Study with a Vector-Based Phase Analysis. Sci Rep 2018; 8:16737. [PMID: 30425287 PMCID: PMC6233191 DOI: 10.1038/s41598-018-35172-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/31/2018] [Indexed: 01/30/2023] Open
Abstract
Attention deficits due to auditory distractibility are pervasive among patients with acquired brain injury (ABI). It remains unclear, however, whether attention deficits following ABI specific to auditory modality are associated with altered haemodynamic responses. Here, we examined cerebral haemodynamic changes using functional near-infrared spectroscopy combined with a topological vector-based analysis method. A total of thirty-seven participants (22 healthy adults, 15 patients with ABI) performed a melodic contour identification task (CIT) that simulates auditory distractibility. Findings demonstrated that the melodic CIT was able to detect auditory distractibility in patients with ABI. The rate-corrected score showed that the ABI group performed significantly worse than the non-ABI group in both CIT1 (target contour identification against environmental sounds) and CIT2 (target contour identification against target-like distraction). Phase-associated response intensity during the CITs was greater in the ABI group than in the non-ABI group. Moreover, there existed a significant interaction effect in the left dorsolateral prefrontal cortex (DLPFC) during CIT1 and CIT2. These findings indicated that stronger hemodynamic responses involving oxygen exchange in the left DLPFC can serve as a biomarker for evaluating and monitoring auditory distractibility, which could potentially lead to the discovery of the underlying mechanism that causes auditory attention deficits in patients with ABI.
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Affiliation(s)
- Eunju Jeong
- Department of Arts and Technology, Hanyang University, Seoul, 04763, Republic of Korea.
- Division of Industrial Information Studies, Hanyang University, Seoul, 04763, Republic of Korea.
| | - Hokyoung Ryu
- Department of Arts and Technology, Hanyang University, Seoul, 04763, Republic of Korea
- Graduate School of Technology and Innovation Management, Hanyang University, Seoul, 04763, Republic of Korea
| | - Joon-Ho Shin
- Department of Neurorehabilitation, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, 01022, Republic of Korea
| | - Gyu Hyun Kwon
- Department of Arts and Technology, Hanyang University, Seoul, 04763, Republic of Korea
- Graduate School of Technology and Innovation Management, Hanyang University, Seoul, 04763, Republic of Korea
| | - Geonsang Jo
- Department of Arts and Technology, Hanyang University, Seoul, 04763, Republic of Korea
| | - Ji-Yeong Lee
- Department of Neurorehabilitation, National Rehabilitation Center, Ministry of Health and Welfare, Seoul, 01022, Republic of Korea
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17
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Hirschi R, Hawryluk GWJ, Nielson JL, Huie JR, Zimmermann LL, Saigal R, Ding Q, Ferguson AR, Manley G. Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold. J Neurosurg 2018; 131:1216-1226. [PMID: 30497191 PMCID: PMC8979548 DOI: 10.3171/2018.4.jns172604] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/23/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain tissue hypoxia is common after traumatic brain injury (TBI). Technology now exists that can detect brain hypoxia and guide corrective therapy. Current guidelines for the management of severe TBI recommend maintaining partial pressure of brain tissue oxygen (PbtO2) > 15-20 mm Hg; however, uncertainty persists as to the optimal treatment threshold. The object of this study was to better inform the relationship between PbtO2 values and outcome for patients with TBI. METHODS PbtO2 measurements were prospectively and automatically collected every minute from consecutive patients admitted to the San Francisco General Hospital neurological ICU during a 6-year period. Mean PbtO2 values in TBI patients as well as the proportion of PbtO2 values below each of 75 thresholds between 0 mm Hg and 75 mm Hg over various epochs up to 30 days from the time of admission were analyzed. Patient outcomes were determined using the Glasgow Outcome Scale. The authors explored putative treatment thresholds by generating 675 separate receiver operating characteristic curves and 675 generalized linear models to examine each 1-mm Hg threshold for various epochs. RESULTS A total of 1,380,841 PbtO2 values were recorded in 190 TBI patients. A high proportion of PbtO2 measures were below 20 mm Hg irrespective of the examined epoch. Time below treatment thresholds was more strongly associated with outcome than mean PbtO2. A treatment window was suggested: a threshold of 19 mm Hg most robustly distinguished patients by outcome, especially from days 3-5; however, benefit was suggested from maintaining values at least as high as 33 mm Hg. CONCLUSIONS This analysis of high-frequency physiological data substantially informs the relationship between PbtO2 values and outcome. The results suggest a therapeutic window for PbtO2 in TBI patients along with minimum and preferred PbtO2 treatment thresholds, which may be examined in future studies. Traditional treatment thresholds that have the strongest association with outcome may not be optimal.
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Affiliation(s)
- Ryan Hirschi
- School of Medicine, University of Utah, Salt Lake City
| | - Gregory W. J. Hawryluk
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Jessica L. Nielson
- Department of Psychiatry, Institute of Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - J. Russell Huie
- Brain and Spinal Injury Center, Weill Institute for Neurosciences, Department of Neurosurgery, San Francisco General Hospital, University of California, San Francisco
| | - Lara L. Zimmermann
- Department of Neurological Surgery, University of California, Davis, Sacramento, California
| | - Rajiv Saigal
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Quan Ding
- Department of Physiologic Nursing, University of California, San Francisco, California
| | - Adam R. Ferguson
- Brain and Spinal Injury Center, Weill Institute for Neurosciences, Department of Neurosurgery, San Francisco General Hospital, University of California, San Francisco
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, California
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18
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Harutyunyan G, Harutyunyan G, Mkhoyan G. New Viewpoint in Exaggerated Increase of PtiO 2 With Normobaric Hyperoxygenation and Reasons to Limit Oxygen Use in Neurotrauma Patients. Front Med (Lausanne) 2018; 5:119. [PMID: 29872657 PMCID: PMC5972302 DOI: 10.3389/fmed.2018.00119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/10/2018] [Indexed: 01/06/2023] Open
Affiliation(s)
| | | | - Gagik Mkhoyan
- Anesthesiology and Intensive Care, Erebouni Medical Center, Yerevan, Armenia
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19
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Jouffroy R, Saade A, Saint Martin LC, Philippe P, Carli P, Vivien B. Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospital invasive ventilation. Am J Emerg Med 2018; 37:56-60. [PMID: 29709397 DOI: 10.1016/j.ajem.2018.04.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/18/2018] [Accepted: 04/22/2018] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Mechanical ventilation can help improve the prognosis of septic shock. While adequate delivery of oxygen to the tissue is crucial, hyperoxemia may be deleterious. Invasive out-of-hospital ventilation is often promptly performed in life-threatening emergencies. We propose to determine whether the arterial oxygen pressure (PaO2) at the intensive care unit (ICU) admission is associated with mortality in patients with septic shock subjected to pre-hospital mechanical ventilation. METHODS We performed a monocentric retrospective observational study on 77 patients. PaO2 was measured at ICU admission. The primary outcome was mortality at day 28 (D28). RESULTS Forty-nine (64%) patients were included. The mean PaO2 at ICU admission was 153 ± 77 and 202 ± 82 mm Hg for alive and deceased patients respectively. Mortality concerned 18% of patients for PaO2 < 100, 25% for 100 < PaO2 < 150 and 57% for a PaO2 > 150 mm Hg. PaO2 was significantly associated with mortality at D28 (p = 0.04). Using propensity score analysis including SOFA score, pre-hospital duration, lactate, and prehospital fluid volume expansion, association with mortality at D28 only remained for PaO2 > 150 mm Hg (p = 0.02, OR [CI95] = 1.59 [1.20-2.10]). CONCLUSIONS In this study, we report a significant association between hyperoxemia at ICU admission and mortality in patients with septic shock subjected to pre-hospital invasive mechanical ventilation. The early adjustment of the PaO2 should be considered for these patients to avoid the toxic effects of hyperoxemia. However, blood gas analysis is hard to get in a prehospital setting. Consequently, alternative and feasible measures are needed, such as pulse oximetry, to improve the management of pre-hospital invasive ventilation.
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Affiliation(s)
- Romain Jouffroy
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France.
| | - Anastasia Saade
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Laure Castres Saint Martin
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Pascal Philippe
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Pierre Carli
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Benoit Vivien
- Department of Anesthesia & Intensive Care Unit, SAMU, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
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20
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Ding J, Zhou D, Sui M, Meng R, Chandra A, Han J, Ding Y, Ji X. The effect of normobaric oxygen in patients with acute stroke: a systematic review and meta-analysis. Neurol Res 2018; 40:433-444. [PMID: 29600891 DOI: 10.1080/01616412.2018.1454091] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Normobaric oxygen (NBO) has received considerable attention due to controversial data in brain protection in patients with acute stroke. This study aims to analyze current data of NBO on brain protection as used in the clinic. Methods We searched for and reviewed relevant articles and references from Pubmed, Medline, Embase, Cochrane, and Clincialtrials.gov that were published prior to October 2017. Data from prospective studies were processed using RevMan5.0 software, provided by Cochrane collaboration and transformed using relevant formulas. Results A total of 11 prospective RCT studies including 6366 patients with acute stroke (NBO group, 3207; control group, 3159) were enrolled in this analysis. △NIHSS represented the values of NIHSS at 4, 24 h, or 7 days post-stroke minus baseline NIHSS. Compared to controls, there was a minor trend toward NBO benefits in short-term prognostic indices, as indicated by decreased ΔNIHSS at our defined time points. By contrast, NBO decreased Barthel Index scores between 3 and 7 months, and increased death rates at 3, 6 months, and 1 year, whereas, modified Rankin Scale scores between 3 and 6 months were unchanged. Conclusions The existing trends toward benefits revealed in this meta-analysis help us appreciate the promising value of NBO, although current evidence of NBO on improving clinical outcomes of stroke is insufficient. Well-designed multi-center clinical trials are encouraged and urgently needed to further explore the efficacy of NBO on brain protection.
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Affiliation(s)
- Jiayue Ding
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Da Zhou
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Meng Sui
- c Department of Economics , Fordham University , Bronx , NY , USA
| | - Ran Meng
- a Department of Neurology , Xuanwu Hospital, Capital Medical University , Beijing , China.,b Beijing Institute for Brain Disorders , Beijing , China
| | - Ankush Chandra
- d Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA.,e Department of Neurosurgery , University of California San Francisco , San Francisco, CA , USA
| | - Jie Han
- f Department of Neurology , The First Affiliated Hospital of Dalian Medical University , Dalian , China
| | - Yuchuan Ding
- d Department of Neurosurgery , Wayne State University School of Medicine , Detroit , MI , USA
| | - Xunming Ji
- b Beijing Institute for Brain Disorders , Beijing , China.,g Department of Neurosurgery , Xuanwu Hospital, Capital Medical University , Beijing , China
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21
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Terraneo L, Samaja M. Comparative Response of Brain to Chronic Hypoxia and Hyperoxia. Int J Mol Sci 2017; 18:ijms18091914. [PMID: 28880206 PMCID: PMC5618563 DOI: 10.3390/ijms18091914] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/01/2017] [Accepted: 09/03/2017] [Indexed: 12/25/2022] Open
Abstract
Two antithetic terms, hypoxia and hyperoxia, i.e., insufficient and excess oxygen availability with respect to needs, are thought to trigger opposite responses in cells and tissues. This review aims at summarizing the molecular and cellular mechanisms underlying hypoxia and hyperoxia in brain and cerebral tissue, a context that may prove to be useful for characterizing not only several clinically relevant aspects, but also aspects related to the evolution of oxygen transport and use by the tissues. While the response to acute hypoxia/hyperoxia presumably recruits only a minor portion of the potentially involved cell machinery, focusing into chronic conditions, instead, enables to take into consideration a wider range of potential responses to oxygen-linked stress, spanning from metabolic to genic. We will examine how various brain subsystems, including energetic metabolism, oxygen sensing, recruitment of pro-survival pathways as protein kinase B (Akt), mitogen-activated protein kinases (MAPK), neurotrophins (BDNF), erythropoietin (Epo) and its receptors (EpoR), neuroglobin (Ngb), nitric oxide (NO), carbon monoxide (CO), deal with chronic hypoxia and hyperoxia to end-up with the final outcomes, oxidative stress and brain damage. A more complex than expected pattern results, which emphasizes the delicate balance between the severity of the stress imposed by hypoxia and hyperoxia and the recruitment of molecular and cellular defense patterns. While for certain functions the expectation that hypoxia and hyperoxia should cause opposite responses is actually met, for others it is not, and both emerge as dangerous treatments.
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Affiliation(s)
- Laura Terraneo
- Department of Health Science, University of Milan, I-20142 Milano, Italy.
| | - Michele Samaja
- Department of Health Science, University of Milan, I-20142 Milano, Italy.
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22
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Grände PO. Critical Evaluation of the Lund Concept for Treatment of Severe Traumatic Head Injury, 25 Years after Its Introduction. Front Neurol 2017; 8:315. [PMID: 28725211 PMCID: PMC5495987 DOI: 10.3389/fneur.2017.00315] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 06/16/2017] [Indexed: 12/24/2022] Open
Abstract
When introduced in 1992, the Lund concept (LC) was the first complete guideline for treatment of severe traumatic brain injury (s-TBI). It was a theoretical approach, based mainly on general physiological principles-i.e., of brain volume control and optimization of brain perfusion and oxygenation of the penumbra zone. The concept gave relatively strict outlines for cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The LC strives for treatment of the pathophysiological mechanisms behind symptoms rather than just treating the symptoms. The treatment is standardized, with less need for individualization. Alternative guidelines published a few years later (e.g., the Brain Trauma Foundation guidelines and European guidelines) were mainly based on meta-analytic approaches from clinical outcome studies and to some extent from systematic reviews. When introduced, they differed extensively from the LC. We still lack any large randomized outcome study comparing the whole concept of BTF guidelines with other guidelines including the LC. From that point of view, there is limited clinical evidence favoring any of the s-TBI guidelines used today. In principle, the LC has not been changed since its introduction. Some components of the alternative guidelines have approached those in the LC. In this review, I discuss some important principles of brain hemodynamics that have been lodestars during formulation of the LC. Aspects of ventilation, nutrition, and temperature control are also discussed. I critically evaluate the most important components of the LC 25 years after its introduction, based on hemodynamic principles and on the results of own an others experimental and human studies that have been published since then.
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Affiliation(s)
- Per-Olof Grände
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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23
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Winkler MKL, Dengler N, Hecht N, Hartings JA, Kang EJ, Major S, Martus P, Vajkoczy P, Woitzik J, Dreier JP. Oxygen availability and spreading depolarizations provide complementary prognostic information in neuromonitoring of aneurysmal subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2017; 37:1841-1856. [PMID: 27025768 PMCID: PMC5435278 DOI: 10.1177/0271678x16641424] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/27/2015] [Accepted: 02/09/2016] [Indexed: 12/19/2022]
Abstract
Multimodal neuromonitoring in neurocritical care increasingly includes electrocorticography to measure epileptic events and spreading depolarizations. Spreading depolarization causes spreading depression of activity (=isoelectricity) in electrically active tissue. If the depression is long-lasting, further spreading depolarizations occur in still isoelectric tissue where no activity can be suppressed. Such spreading depolarizations are termed isoelectric and are assumed to indicate energy compromise. However, experimental and clinical recordings suggest that long-lasting spreading depolarization-induced depression and isoelectric spreading depolarizations are often recorded outside of the actual ischemic zones, allowing the remote diagnosis of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Here, we analyzed simultaneous electrocorticography and tissue partial pressure of oxygen recording in 33 aneurysmal subarachnoid hemorrhage patients. Multiple regression showed that both peak total depression duration per recording day and mean baseline tissue partial pressure of oxygen were independent predictors of outcome. Moreover, tissue partial pressure of oxygen preceding spreading depolarization was similar and differences in tissue partial pressure of oxygen responses to spreading depolarization were only subtle between isoelectric spreading depolarizations and spreading depressions. This further supports that, similar to clustering of spreading depolarizations, long spreading depolarization-induced periods of isoelectricity are useful to detect energy compromise remotely, which is valuable because the exact location of future developing pathology is unknown at the time when the neurosurgeon implants recording devices.
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Affiliation(s)
- Maren KL Winkler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Nora Dengler
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Nils Hecht
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Eun J Kang
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
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24
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Terraneo L, Paroni R, Bianciardi P, Giallongo T, Carelli S, Gorio A, Samaja M. Brain adaptation to hypoxia and hyperoxia in mice. Redox Biol 2016; 11:12-20. [PMID: 27835780 PMCID: PMC5107733 DOI: 10.1016/j.redox.2016.10.018] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/23/2016] [Accepted: 10/27/2016] [Indexed: 12/13/2022] Open
Abstract
Aims Hyperoxic breathing might lead to redox imbalance and signaling changes that affect cerebral function. Paradoxically, hypoxic breathing is also believed to cause oxidative stress. Our aim is to dissect the cerebral tissue responses to altered O2 fractions in breathed air by assessing the redox imbalance and the recruitment of the hypoxia signaling pathways. Results Mice were exposed to mild hypoxia (10%O2), normoxia (21%O2) or mild hyperoxia (30%O2) for 28 days, sacrificed and brain tissue excised and analyzed. Although one might expect linear responses to %O2, only few of the examined variables exhibited this pattern, including neuroprotective phospho- protein kinase B and the erythropoietin receptor. The major reactive oxygen species (ROS) source in brain, NADPH oxidase subunit 4 increased in hypoxia but not in hyperoxia, whereas neither affected nuclear factor (erythroid-derived 2)-like 2, a transcription factor that regulates the expression of antioxidant proteins. As a result of the delicate equilibrium between ROS generation and antioxidant defense, neuron apoptosis and cerebral tissue hydroperoxides increased in both 10%O2 and 30%O2, as compared with 21%O2. Remarkably, the expression level of hypoxia-inducible factor (HIF)−2α (but not HIF-1α) was higher in both 10%O2 and 30%O2 with respect to 21%O2 Innovation Comparing the in vivo effects driven by mild hypoxia with those driven by mild hyperoxia helps addressing whether clinically relevant situations of O2 excess and scarcity are toxic for the organism. Conclusion Prolonged mild hyperoxia leads to persistent cerebral damage, comparable to that inferred by prolonged mild hypoxia. The underlying mechanism appears related to a model whereby the imbalance between ROS generation and anti-ROS defense is similar, but occurs at higher levels in hypoxia than in hyperoxia. Both oxygen scarcity and oxygen excess are harmful for the brain. Hypoxia increases ROS more than hyperoxia. Hypoxia increases the antioxidant defenses to an extent larger than hyperoxia. Both hypoxia and hyperoxia imbalance the ROS generation/ antiROS defense equilibrium. These findings have implications for those who need supplemental oxygen therapy.
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Affiliation(s)
- Laura Terraneo
- Department of Health Science, University of Milan, 20142 Milan, Italy
| | - Rita Paroni
- Department of Health Science, University of Milan, 20142 Milan, Italy
| | - Paola Bianciardi
- Department of Health Science, University of Milan, 20142 Milan, Italy
| | | | - Stephana Carelli
- Department of Health Science, University of Milan, 20142 Milan, Italy
| | - Alfredo Gorio
- Department of Health Science, University of Milan, 20142 Milan, Italy
| | - Michele Samaja
- Department of Health Science, University of Milan, 20142 Milan, Italy.
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Quintard H, Patet C, Suys T, Marques-Vidal P, Oddo M. Normobaric hyperoxia is associated with increased cerebral excitotoxicity after severe traumatic brain injury. Neurocrit Care 2016; 22:243-50. [PMID: 25168744 DOI: 10.1007/s12028-014-0062-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Normobaric oxygen therapy is frequently applied in neurocritical care, however, whether supplemental FiO2 has beneficial cerebral effects is still controversial. We examined in patients with severe traumatic brain injury (TBI) the effect of incremental FiO2 on cerebral excitotoxicity, quantified by cerebral microdialysis (CMD) glutamate. METHODS This was a retrospective analysis of a database of severe TBI patients monitored with CMD and brain tissue oxygen (PbtO2). The relationship of FiO2--categorized into four separate ranges (<40, 41-60, 61-80, and >80 %)--with CMD glutamate was examined using ANOVA with Tukey's post hoc test. RESULTS A total of 1,130 CMD samples from 36 patients--monitored for a median of 4 days--were examined. After adjusting for brain (PbtO2, intracranial pressure, cerebral perfusion pressure, lactate/pyruvate ratio, Marshall CT score) and systemic (PaCO2, PaO2, hemoglobin, APACHE score) covariates, high FiO2 was associated with a progressive increase in CMD glutamate [8.8 (95 % confidence interval 7.4-10.2) µmol/L at FiO2 < 40 % vs. 12.8 (10.9-14.7) µmol/L at 41-60 % FiO2, 19.3 (15.6-23) µmol/L at 61-80 % FiO2, and 22.6 (16.7-28.5) µmol/L at FiO2 > 80 %; multivariate-adjusted p < 0.05]. The threshold of FiO2-related increase in CMD glutamate was lower for samples with normal versus low PbtO2 < 20 mmHg (FiO2 > 40 % vs. FiO2 > 60 %). Hyperoxia (PaO2 > 150 mmHg) was also associated with increased CMD glutamate (adjusted p < 0.001). CONCLUSIONS Incremental normobaric FiO2 levels were associated with increased cerebral excitotoxicity in patients with severe TBI, independent from PbtO2 and other important cerebral and systemic determinants. These data suggest that supra-normal oxygen may aggravate secondary brain damage after severe TBI.
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Affiliation(s)
- Hervé Quintard
- Department of Intensive Care Medicine, Neuroscience Critical Care Research Group Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital, Rue du Bugnon 46, BH 08.623, 1011, Lausanne, Switzerland
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Abstract
OPINION STATEMENT The acute treatment of major ischemic stroke has been revolutionized by strong and consistent evidence from multiple randomized trials. Endovascular treatment by mechanical thrombectomy will be increasingly chosen as an adjunctive or alternative to intravenous thrombolysis. To apply this form of stroke treatment is associated with the challenge of optimal periinterventional treatment. The patient has to be identified, counselled, prepared, monitored, cardiovascularly stabilized, possibly sedated and ventilated, and postprocedurally treated in the optimal way. However, most aspects of periinterventional treatment have as yet not been clarified and require prospective research. Among these, the question of general anesthesia vs conscious sedation has received most attention and may be the most crucial one. Based on a great amount of retrospective data, it appears reasonable to start the intervention under conscious sedation of the non-intubated patient with standby measures for emergent intubation, until prospective randomized trials have clarified that issue. Periinterventional management will significantly affect the success of recanalization.
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Affiliation(s)
- Julian Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
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Weaver J, Liu KJ. Does normobaric hyperoxia increase oxidative stress in acute ischemic stroke? A critical review of the literature. Med Gas Res 2015; 5:11. [PMID: 26306184 PMCID: PMC4547432 DOI: 10.1186/s13618-015-0032-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/02/2015] [Indexed: 12/22/2022] Open
Abstract
Stroke, one of the most debilitating cerebrovascular and nuerological diseases, is a serious life-threatening condition and a leading cause of long-term adult disability and brain damage, either directly or by secondary complications. Most effective treatments for stroke are time dependent such as the only FDA-approved therapy, reperfusion with tissue-type plasminogen activator; thus, improving tissue oxygenation with normobaric hyperoxia (NBO) has been considered a logical and potential important therapy. NBO is considered a good approach because of its potential clinical advantages, and many studies suggest that NBO is neuroprotective, reducing ischemic brain injury and infarct volume in addition to improving pathologic and neurobehavorial outcomes. However, increased reactive oxygen species (ROS) generation may occur when tissue oxygen level is too high or too low. Therefore, a major concern with NBO therapy in acute ischemic stroke is the potential increase of ROS, which could exacerbate brain injury. The purpose of this review is to critically review the current literature reports on the effect of NBO treatment on ROS and oxidative stress with respect to acute ischemic stroke. Considering the available data from relevant animal models, NBO does not increase ROS or oxidative stress if applied for a short duration; therefore, the potential that NBO is a viable neuroprotective strategy for acute ischemic stroke is compelling. The benefits of NBO may significantly outweigh the risks of potential increase in ROS generation for the treatment of acute ischemic stroke.
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Affiliation(s)
- John Weaver
- Department of Pharmaceutical Sciences, College of Pharmacy, BRaIN Imaging Center, MSC10 5620, 1 University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA ; Center of Biomedical Research Excellence, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA
| | - Ke Jian Liu
- Department of Pharmaceutical Sciences, College of Pharmacy, BRaIN Imaging Center, MSC10 5620, 1 University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA ; Center of Biomedical Research Excellence, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA ; Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131 USA
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Damiani E, Adrario E, Girardis M, Romano R, Pelaia P, Singer M, Donati A. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta-analysis. Crit Care 2014; 18:711. [PMID: 25532567 PMCID: PMC4298955 DOI: 10.1186/s13054-014-0711-x] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 12/08/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The safety of arterial hyperoxia is under increasing scrutiny. We performed a systematic review of the literature to determine whether any association exists between arterial hyperoxia and mortality in critically ill patient subsets. METHODS Medline, Thomson Reuters Web of Science and Scopus databases were searched from inception to June 2014. Observational or interventional studies evaluating the relationship between hyperoxia (defined as a supranormal arterial O2 tension) and mortality in adult intensive care unit (ICU) patients were included. Studies primarily involving patients with exacerbations of chronic pulmonary disease, acute lung injury and perioperative administration were excluded. Adjusted odds ratio (OR) of patients exposed versus those not exposed to hyperoxia were extracted, if available. Alternatively, unadjusted outcome data were recorded. Data on patients, study characteristics and the criteria used for defining hyperoxia exposure were also extracted. Random-effects models were used for quantitative synthesis of the data, with a primary outcome of hospital mortality. RESULTS In total 17 studies (16 observational, 1 prospective before-after) were identified in different patient categories: mechanically ventilated ICU (number of studies (k) = 4, number of participants (n) = 189,143), post-cardiac arrest (k = 6, n = 19,144), stroke (k = 2, n = 5,537), and traumatic brain injury (k = 5, n = 7,488). Different criteria were used to define hyperoxia in terms of PaO2 value (first, highest, worst, mean), time of assessment and predetermined cutoffs. Data from studies on ICU patients were not pooled because of extreme heterogeneity (inconsistency (I(2)) 96.73%). Hyperoxia was associated with increased mortality in post-cardiac arrest patients (OR = 1.42 (1.04 to 1.92) I(2) 67.73%) stroke (OR = 1.23 (1.06 to 1.43) I(2) 0%) and traumatic brain injury (OR = 1.41 (1.03 to 1.94) I(2) 64.54%). However, these results are limited by significant heterogeneity between studies. CONCLUSIONS Hyperoxia may be associated with increased mortality in patients with stroke, traumatic brain injury and those resuscitated from cardiac arrest. However, these results are limited by the high heterogeneity of the included studies.
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Affiliation(s)
- Elisa Damiani
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10, 60126, Torrette di Ancona, Italy.
| | - Erica Adrario
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10, 60126, Torrette di Ancona, Italy.
| | - Massimo Girardis
- Department of Anaesthesia and Intensive Care, University Hospital of Modena, Via del Pozzo 71, 41124, Modena, Italy.
| | - Rocco Romano
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10, 60126, Torrette di Ancona, Italy.
| | - Paolo Pelaia
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10, 60126, Torrette di Ancona, Italy.
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Abele Donati
- Anaesthesia and Intensive Care Unit, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, via Tronto 10, 60126, Torrette di Ancona, Italy.
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Narotam PK, Morrison JF, Schmidt MD, Nathoo N. Physiological complexity of acute traumatic brain injury in patients treated with a brain oxygen protocol: utility of symbolic regression in predictive modeling of a dynamical system. J Neurotrauma 2014; 31:630-41. [PMID: 24195645 DOI: 10.1089/neu.2013.3104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Predictive modeling of emergent behavior, inherent to complex physiological systems, requires the analysis of large complex clinical data streams currently being generated in the intensive care unit. Brain tissue oxygen protocols have yielded outcome benefits in traumatic brain injury (TBI), but the critical physiological thresholds for low brain oxygen have not been established for a dynamical patho-physiological system. High frequency, multi-modal clinical data sets from 29 patients with severe TBI who underwent multi-modality neuro-clinical care monitoring and treatment with a brain oxygen protocol were analyzed. The inter-relationship between acute physiological parameters was determined using symbolic regression (SR) as the computational framework. The mean patient age was 44.4±15 with a mean admission GCS of 6.6±3.9. Sixty-three percent sustained motor vehicle accidents and the most common pathology was intra-cerebral hemorrhage (50%). Hospital discharge mortality was 21%, poor outcome occurred in 24% of patients, and good outcome occurred in 56% of patients. Criticality for low brain oxygen was intracranial pressure (ICP) ≥22.8 mm Hg, for mortality at ICP≥37.1 mm Hg. The upper therapeutic threshold for cerebral perfusion pressure (CPP) was 75 mm Hg. Eubaric hyperoxia significantly impacted partial pressure of oxygen in brain tissue (PbtO2) at all ICP levels. Optimal brain temperature (Tbr) was 34-35°C, with an adverse effect when Tbr≥38°C. Survivors clustered at [Formula: see text] Hg vs. non-survivors [Formula: see text] 18 mm Hg. There were two mortality clusters for ICP: High ICP/low PbtO2 and low ICP/low PbtO2. Survivors maintained PbtO2 at all ranges of mean arterial pressure in contrast to non-survivors. The final SR equation for cerebral oxygenation is: [Formula: see text]. The SR-model of acute TBI advances new physiological thresholds or boundary conditions for acute TBI management: PbtO2≥25 mmHg; ICP≤22 mmHg; CPP≈60-75 mmHg; and Tbr≈34-37°C. SR is congruous with the emerging field of complexity science in the modeling of dynamical physiological systems, especially during pathophysiological states. The SR model of TBI is generalizable to known physical laws. This increase in entropy reduces uncertainty and improves predictive capacity. SR is an appropriate computational framework to enable future smart monitoring devices.
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Arikan F, Vilalta J, Torne R, Chocron I, Rodriguez-Tesouro A, Sahuquillo J. Monitorización intraoperatoria de la presión tisular de oxígeno: aplicaciones en neurocirugía vascular. Neurocirugia (Astur) 2014; 25:275-85. [DOI: 10.1016/j.neucir.2014.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/17/2014] [Accepted: 03/23/2014] [Indexed: 10/25/2022]
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Williams D, Calder S, Cocchi MN, Donnino MW. From door to recovery: a collaborative approach to the development of a post-cardiac arrest center. Crit Care Nurse 2014; 33:42-54. [PMID: 24085827 DOI: 10.4037/ccn2013341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Out-of-hospital cardiac arrest remains common and, despite advances in resuscitation practices, continues to carry a high mortality that may be influenced by several factors, including where a patient is cared for after the cardiac arrest. Implementing a post-cardiac arrest care guideline for survivors of out-of-hospital and in-hospital cardiac arrest involves a multidisciplinary approach with short-term and long-term strategies. Physician and nursing leaders must work in synergy to guide the implementation of an evidence-based plan of care. A collaborative approach was used at a hospital to develop processes, build consensus for protocols, and provide support to staff and teams. A joint approach has allowed the hospital to move from traditional silos of individual departmental care to a continuum of patient-focused management after cardiac arrest. This care coordination is initiated in the emergency department and follows the patient through to discharge.
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Ridler N, Plumb J, Grocott M. Oxygen Therapy in Critical Illness: Friend or Foe? A Review of Oxygen Therapy in Selected Acute Illnesses. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500303] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In recent years there has been a gradual shift away from using uncontrolled high concentrations of inspired oxygen in some acute illnesses. Oxygen is perhaps the most frequently used drug in medicine, and understanding the balance of benefits and harms is essential knowledge for all anaesthetists and intensivists. While current teaching and practice emphasise avoiding hypoxaemia over concerns about hyperoxaemia, it may transpire that oxygen excess is more harmful than previously thought. As with many interventions in intensive care medicine, striving to achieve physiological normality may sometimes do more harm than good, and tolerance of abnormal values may on occasion be in patients' best interests. Incorporating Single Best Answers (see page 197: answers on page 237).
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McMullan J, Rodriquez D, Hart KW, Lindsell CJ, Vonderschmidt K, Wayne B, Branson R. Prevalence of prehospital hypoxemia and oxygen use in trauma patients. Mil Med 2014; 178:1121-5. [PMID: 24083926 DOI: 10.7205/milmed-d-13-00126] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE This study estimates the prevalence of injured patients requiring prehospital supplemental oxygen based on existing recommendations, and determines whether actual use exceeds those recommendations. PATIENTS AND METHODS Prehospital oxygen use and continuous peripheral oxygen saturation measurements were prospectively collected on a purposive sample of injured civilians transported to an urban level 1 trauma center by paramedics. Structured chart review determined injury characteristics and outcomes. Supplemental oxygen administration indications were hypoxemia (peripheral oxygen saturation ≤ 90%), hemorrhagic shock (systolic blood pressure < 100 mmHg), or paramedic suspicion of traumatic brain injury. RESULTS Paramedics enrolled 224/290 screened subjects. Median (range) age was 34 (18-84) years, 48.7% were nonwhite, 75.4% were male, and Injury Severity Score was 5 (1-75). Half (54.5%) were admitted; 36.2% sustained a penetrating injury. None underwent prehospital endotracheal intubation. Hypoxemia occurred in 86 (38.4%), paramedics suspected traumatic brain injury in 22 (9.8%), and 20 (8.9%) were hypotensive. Any indication for supplemental oxygen (107/224 [47.8%, 95%CI 41.3%-54.3%]) and prehospital administration of oxygen (141/224 [62.9%, 95%CI 56.2%-69.2%]) was common. Many (35/141 [24.8%]) received oxygen without indication. CONCLUSIONS On the basis of current guidelines, less than half of adult trauma patients have an indication for prehospital supplemental oxygen, yet is frequently administered in the absence of clinical indication.
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Affiliation(s)
- Jason McMullan
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way ML0769, Cincinnati, OH 45267-0769
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Carre E, Ogier M, Boret H, Montcriol A, Bourdon L, Jean-Jacques R. Metabolic crisis in severely head-injured patients: is ischemia just the tip of the iceberg? Front Neurol 2013; 4:146. [PMID: 24130548 PMCID: PMC3795329 DOI: 10.3389/fneur.2013.00146] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 09/16/2013] [Indexed: 01/05/2023] Open
Abstract
Ischemia and metabolic crisis are frequent post-traumatic secondary brain insults that negatively influence outcome. Clinicians commonly mix up these two types of insults, mainly because high lactate/pyruvate ratio (LPR) is the common marker for both ischemia and metabolic crisis. However, LPR elevations during ischemia and metabolic crisis reflect two different energetic imbalances: ischemia (Type 1 LPR elevations with low oxygenation) is characterized by a drastic deprivation of energetic substrates, whereas metabolic crisis (Type 2 LPR elevations with normal or high oxygenation) is associated with profound mitochondrial dysfunction but normal supply of energetic substrates. The discrimination between ischemia and metabolic crisis is crucial because conventional recommendations against ischemia may be detrimental for patients with metabolic crisis. Multimodal monitoring, including microdialysis and brain tissue oxygen monitoring, allows such discrimination, but these techniques are not easily accessible to all head-injured patients. Thus, a new “gold standard” and adapted medical education are required to optimize the management of patients with metabolic crisis.
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Affiliation(s)
- Emilie Carre
- Unit of Traumatology, Institut de Recherche Biomedicale des Armees , Bretigny , France
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Minor hemoglobins HbA2 and HbF associate with disease severity in bipolar disorder with a likely protective role of HbA2 against post-partum episodes. J Affect Disord 2013; 151:405-8. [PMID: 23856286 DOI: 10.1016/j.jad.2013.06.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/18/2013] [Accepted: 06/18/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND There exist studies indicating that bipolar disorder (BD) associates with changes in brain blood flow. Human brain with its high demand to oxygen constitutes 2% of the total body weight, while it receives 20% of cardiac output. α and β globin chains of hemoglobin were recently found in neural tissues, yet no study has questioned blood hemoglobins in BD. METHODS A total of 120 euthymic BD patients (40 males and 80 females) were analyzed via high performance liquid chromatography (HPLC) to measure minor hemoglobin levels, which were statistically compared with disease characteristics. RESULTS Minor hemoglobins HbA2 and HbF associated positively with episode density as a measure of disease severity in BD. An increased level of HbA2 meant significantly less postpartum episodes in child bearing women. HbF levels were higher in patients with a positive family history of any psychotic disorder. Sum of HbA2 and HbF correlated with episode density with a stronger significance (p<0.001) supporting intermittent hypoxia hypothesis in BD. LIMITATIONS The study was conducted only on euthymic patients to avoid likely bigger exogenous effects such as electro-convulsive therapy and diverse drug regimes, yet larger comparative studies are needed to support our current findings. CONCLUSIONS Higher HbA2 and HbF in more severe bipolar disorder may be compensations against intermittent hypoxias in BD. HbA2 increases following myocardial angina and in mountain dwellers, which may indicate protective roles in extreme conditions. HbF increase may act more as a maladaptation or emerge via haplotypal associations of BD genes and gamma-globin locus at 11p15.5.
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Klychnikova EV, Tazina EV, Solodov AA, Petrikov SS, Godkov MA, Krylov VV. The effects of normobaric hyperoxia on oxidative stress and factors of endogenous vascular regulation in patients who suffered from non-traumatic subarachnoid hemorrhages and remained in critical condition. NEUROCHEM J+ 2013. [DOI: 10.1134/s1819712413030057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Fontes MT, McDonagh DL, Phillips-Bute B, Welsby IJ, Podgoreanu MV, Fontes ML, Stafford-Smith M, Newman MF, Mathew JP. Arterial hyperoxia during cardiopulmonary bypass and postoperative cognitive dysfunction. J Cardiothorac Vasc Anesth 2013; 28:462-6. [PMID: 23972739 DOI: 10.1053/j.jvca.2013.03.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the effect of arterial normobaric hyperoxia during cardiopulmonary bypass (CPB) on postoperative neurocognitive function. The authors hypothesized that arterial hyperoxia during CPB is associated with neurocognitive decline at 6 weeks after cardiac surgery. DESIGN Retrospective study of patients undergoing cardiac surgery with CPB. SETTING A university hospital. PARTICIPANTS One thousand eighteen patients undergoing coronary artery bypass graft (CABG) or CABG + valve surgery with CPB who previously had been enrolled in prospective cognitive trials. INTERVENTIONS A battery of neurocognitive measures was administered at baseline and 6 weeks after surgery. Anesthetic and surgical care was managed as clinically indicated. MEASUREMENTS AND MAIN RESULTS Arterial hyperoxia was assessed primarily as the area under the curve (AUC) for the duration that PaO2 exceeded 200 mmHg during CPB and secondarily as the mean PaO2 during bypass, as a PaO2 = 300 mmHg at any point and as AUC>150 mmHg. Cognitive change was assessed both as a continuous change score and a dichotomous deficit rate. Multivariate regression accounting for age, years of education, baseline cognition, date of surgery, baseline postintubation PaO2, duration of CPB, and percent change in hematocrit level from baseline to lowest level during CPB revealed no significant association between hyperoxia during CPB and postoperative neurocognitive function. CONCLUSIONS Arterial hyperoxia during CPB was not associated with neurocognitive decline after 6 weeks in cardiac surgical patients.
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Affiliation(s)
- Monique T Fontes
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - David L McDonagh
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Manuel L Fontes
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC.
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Le Roux PD, Oddo M. Parenchymal brain oxygen monitoring in the neurocritical care unit. Neurosurg Clin N Am 2013; 24:427-39. [PMID: 23809036 DOI: 10.1016/j.nec.2013.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients admitted to the neurocritical care unit (NCCU) often have serious conditions that can be associated with high morbidity and mortality. Pharmacologic agents or neuroprotectants have disappointed in the clinical environment. Current NCCU management therefore is directed toward identification, prevention, and treatment of secondary cerebral insults that evolve over time and are known to aggravate outcome. This strategy is based on a variety of monitoring techniques including use of intraparenchymal monitors. This article reviews parenchymal brain oxygen monitors, including the available technologies, practical aspects of use, the physiologic rationale behind their use, and patient management based on brain oxygen.
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Affiliation(s)
- Peter D Le Roux
- The Brain and Spine Center, Lankenau Medical Center, 100 E. Lancaster Ave, Wynnewood, PA 19096, USA.
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Admission oxygenation and ventilation parameters associated with discharge survival in severe pediatric traumatic brain injury. Childs Nerv Syst 2013. [PMID: 23207977 PMCID: PMC3596474 DOI: 10.1007/s00381-012-1984-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Current Brain Trauma Foundation guidelines recommend avoiding hypoxemia after severe pediatric traumatic brain injury (TBI). Yet, recent studies on optimum admission oxygenation and ventilation parameters associated with discharge survival in pediatric TBI are lacking. MATERIALS AND METHODS After IRB approval, a retrospective study involving pediatric patients ages ≤14 years with severe TBI (head Abbreviated Injury Scale (AIS) score of ≥3, Glasgow Coma Scale score of ≤8 on admission) admitted to Harborview Medical Center (level 1 pediatric trauma center), Seattle, WA, during 2003 to 2007 was performed. Admission demographics, clinical data, and laboratory characteristics were abstracted. Hypoxemia was defined as PaO2 < 60 mmHg, hypocarbia was defined as PaCO2 ≤ 35 mmHg, and hypercarbia was defined as PaCO2 ≥ 46 mmHg. RESULTS One hundred ninety-four patients met inclusion criteria of which 162 (83.5 %) patients survived. Admission hypoxemia occurred in nine (5.6 %) patients who survived and eight (25 %) patients who died (p < 0.001). Children with admission PaCO2 between 36 and 45 mmHg had greater discharge survival compared with those with both admission hypocarbia (PaCO2 ≤ 35 mmHg) and hypercarbia (PaCO2 ≥ 46 mmHg). Admission PaO2 301-500 mmHg (adjusted odds ratio (AOR), 8.02 (95 % confidence interval (CI), 1.73-37.10); p = 0.008) and admission PaCO2 = 36-45 mmHg (AOR, 5.47 (95 % CI, 1.30-23.07); p = 0.02) were independently associated with discharge survival. CONCLUSIONS Discharge survival after severe pediatric TBI was associated with admission PaO2 301-500 mmHg and PaCO2 = 36-45 mmHg. Admission hypocarbia and hypercarbia were each associated with increased discharge mortality.
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Benderro GF, Sun X, Kuang Y, Lamanna JC. Decreased VEGF expression and microvascular density, but increased HIF-1 and 2α accumulation and EPO expression in chronic moderate hyperoxia in the mouse brain. Brain Res 2012; 1471:46-55. [PMID: 22820296 DOI: 10.1016/j.brainres.2012.06.055] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/09/2012] [Accepted: 06/28/2012] [Indexed: 12/01/2022]
Abstract
Normal brain function is dependent on continuous and controlled oxygen delivery. Chronic moderate hypoxia leads to angiogenesis, suggesting a modulatory role for oxygen in determining capillary density. The objective of this study was to determine physiologic and brain angiogenic adaptational changes during chronic moderate normobaric hyperoxia in mice. Four-month old C56BL/6J mice were kept in a normobaric chamber at 50% O(2) for up to 3 weeks. Normoxic littermates were kept in the same room outside the chamber. Freshly collected or fixed brain specimens were analyzed by RT-PCR, Western blot analysis and immunohistochemistry. Results show accumulation of hypoxia inducible factors 1 and 2α (HIF-1 and 2α), and increased expression of erythropoietin (EPO), cyclooxygenase-2 (COX-2) and angiopoietin-2 (Ang-2). Conversely, vascular endothelial growth factor (VEGF), and VEGF receptor-2 (KDR/Flk-1), Peroxisome proliferator-activated receptor gamma coactivator 1-α (PGC-1α) and prolylhydroxylase-2 (PHD-2) expressions were decreased. VEGF mRNA level was diminished but there was no change in HIF-1α mRNA and von Hippel Lindau E3 ubiquitin ligase (VHL) protein expression. Microvascular density was significantly diminished by the end of the 3rd week of hyperoxia. Overall, our results are: (1) increased expression of the potent neuroprotective molecule, EPO; (2) diminished expression of the potent angiogenic factor, VEGF; and (3) decreased microvascular density. We can, therefore, conclude that brain microvascular density can be controlled by HIF-independent mechanisms, and that brain capillary density is a continuously adjusted variable with tissue oxygen availability as one of the controlling modulators.
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Affiliation(s)
- Girriso F Benderro
- Department of Anatomy, Case Western Reserve University, Cleveland, OH, USA
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Advanced neuromonitoring and imaging in pediatric traumatic brain injury. Crit Care Res Pract 2012; 2012:361310. [PMID: 22675618 PMCID: PMC3363371 DOI: 10.1155/2012/361310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Accepted: 03/22/2012] [Indexed: 12/22/2022] Open
Abstract
While the cornerstone of monitoring following severe pediatric traumatic brain injury is serial neurologic examinations, vital signs, and intracranial pressure monitoring, additional techniques may provide useful insight into early detection of evolving brain injury. This paper provides an overview of recent advances in neuromonitoring, neuroimaging, and biomarker analysis of pediatric patients following traumatic brain injury.
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Hommers C. Hyperoxia post-cardiac arrest – The debate continues? Resuscitation 2012; 83:403-4. [DOI: 10.1016/j.resuscitation.2012.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 01/31/2012] [Indexed: 10/14/2022]
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Bigdeli MR, Asheghabadi M, Khalili A. Time course of neuroprotection induced by normobaric hyperoxia in focal cerebral ischemia. Neurol Res 2012; 34:439-46. [PMID: 22449485 DOI: 10.1179/1743132812y.0000000013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The purpose of this study was to determine if normobaric hyperoxia (HO) preconditioning offers durable neuroprotection against cerebral ischemia and the role of reactive oxygen species in the ischemic tolerance mechanism. MATERIALS AND METHODS Rats were divided into four experimental main groups. First main group which was comprised four subgroups, were exposed to 90% HO for 6 days, 4 hours per day and subjected to 60 minutes of right middle cerebral artery occlusion (MCAO) after 2, 5, 10, and 15 days. Second group acted as control, was exposed to 21% oxygen (RA; room air) in the same chamber, and subjected to 60 minutes of right MCAO. Third main group comprised two subgroups, were exposed to 90% HO for 6 days, 4 hours per day, received normal saline (NS; 2HO+NS) and dimethylthiourea (DT) just before inhaling 90% HO (2HO+DT). Forth main group was exposed to 21% oxygen (2RA) in the same chamber and received normal saline (2RA+NS) and DT just before inhaling 21% oxygen (2RA+DT). Last two main groups were subjected to 60 minutes of right MCAO after 2 days. After 24-hour reperfusion, neurological deficit score (NDS), infarct volume, brain water content, and Evans blue extravasations were assessed in all animals. RESULTS First main group compared with the RA group, NDS, infarct volume, Brain water content, and Evans blue extravasations were reduced in 2, 5, and 10 days significantly, whereas there was no difference among groups 2HO+DT, 2RA+DT, and 2RA+NS. CONCLUSIONS In the model of transient focal cerebral ischemia, hyperoxia preconditioning induced effective but transient neuroprotective effects.
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Francony G, Bouzat P, Picard J, Fevre MC, Gay S, Payen JF. [Normobaric hyperoxia therapy for patients with traumatic brain injury]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:224-227. [PMID: 22305404 DOI: 10.1016/j.annfar.2011.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 11/09/2011] [Indexed: 05/31/2023]
Abstract
Cerebral ischaemia plays a major role in the outcome of brain-injured patients. Because brain oxygenation can be assessed at bedside using intra-parenchymal devices, there has been a growing interest about whether therapeutic hyperoxia could be beneficial for severely head-injured patients. Normobaric hyperoxia increases brain oxygenation and may improve glucose-lactate metabolism in brain regions at risk for ischaemia. However, benefits of normobaric hyperoxia on neurological outcome are not established yet, that hinders the systematic use of therapeutic hyperoxia in head-injured patients. This therapeutic option might be proposed when brain ischemia persists despite the optimization of cerebral blood flow and arterial oxygen blood content.
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Affiliation(s)
- G Francony
- Pôle anesthésie-réanimation, hôpital Michallon, BP 217, 38043 Grenoble cedex 09, France
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Diringer MN, Zazulia AR, Powers WJ. Does Ischemia Contribute to Energy Failure in Severe TBI? Transl Stroke Res 2011; 2:517-23. [DOI: 10.1007/s12975-011-0119-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 10/12/2011] [Accepted: 10/14/2011] [Indexed: 12/12/2022]
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Revuelto-Rey J, Egea-Guerrero JJ, Muñoz-Sánchez MA, Murillo-Cabezas F. [Cerebral microdialysis in the current clinical setting]. Med Intensiva 2011; 36:213-9. [PMID: 21999949 DOI: 10.1016/j.medin.2011.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 08/15/2011] [Accepted: 08/29/2011] [Indexed: 12/27/2022]
Abstract
Cerebral microdialysis, introduced in experimental studies 40 years ago, has been used clinically since 1992 for the neurochemical monitoring of patients in intensive care. The principles underlying this technique are closely related to brain metabolism. The study of the metabolites detected at brain interstitial tissue level, through the semipermeable membrane of the device, allows us to assess different physiological pathways in the brain, analyzing the changes that occur when they become less efficient in terms of energy, and also detecting waste products secondary to tissue damage. Despite its current limitations, this technique provides relevant information for research and the clinical management of critical neurological patients.
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Affiliation(s)
- J Revuelto-Rey
- Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España.
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Brain oxygen tension monitoring following penetrating ballistic-like brain injury in rats. J Neurosci Methods 2011; 203:115-21. [PMID: 21983109 DOI: 10.1016/j.jneumeth.2011.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 09/22/2011] [Accepted: 09/23/2011] [Indexed: 11/22/2022]
Abstract
While brain oxygen tension (PbtO(2)) monitoring is an important parameter for evaluating injury severity and therapeutic efficiency in severe traumatic brain injury (TBI) patients, many factors affect the monitoring. The goal of this study was to identify the effects of FiO(2) (fraction of inspired oxygen) on PbtO(2) in uninjured anesthetized rats and measure the changes in PbtO(2) following penetrating ballistic-like brain injury (PBBI). Continuous PbtO(2) monitoring in uninjured anesthetized rats showed that PbtO(2) response was positively correlated with FiO(2) (0.21-0.35) but PbtO(2) remained stable when FiO(2) was maintained at ∼0.26. Importantly, although increasing FiO(2) from 0.21 to 0.35 improved P(a)O(2), it concomitantly reduced pH levels and elevated P(a)CO(2) values out of the normal range. However, when the FiO(2) was maintained between 0.26 and 0.30, the pH and P(a)O(2) levels remained within the normal or clinically acceptable range. In PBBI rats, PbtO(2) was significantly reduced by ∼40% (16.9 ± 1.2 mm Hg) in the peri-lesional region immediately following unilateral, frontal 10% PBBI compared to sham rats (28.6 ± 1.7 mm Hg; mean ± SEM, p<0.05) and the PBBI-induced reductions in PbtO(2) were sustained for at least 150 min post-PBBI. Collectively, these results demonstrate that FiO(2) affects PbtO(2) and that PBBI produces acute and sustained hypoxia in the peri-lesional region of the brain injury. This study provides important information for the management of PbtO(2) monitoring in this brain injury model and may offer insight for therapeutic strategies targeted to improve the hypoxia/ischemia state in the penetrating-type brain injury.
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Nangunoori R, Maloney-Wilensky E, Stiefel M, Park S, Andrew Kofke W, Levine JM, Yang W, Le Roux PD. Brain Tissue Oxygen-Based Therapy and Outcome After Severe Traumatic Brain Injury: A Systematic Literature Review. Neurocrit Care 2011; 17:131-8. [DOI: 10.1007/s12028-011-9621-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Reduced brain tissue oxygen in traumatic brain injury: are most commonly used interventions successful? ACTA ACUST UNITED AC 2011; 70:535-46. [PMID: 21610340 DOI: 10.1097/ta.0b013e31820b59de] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Brain tissue oxygenation (PbtO2)-guided management facilitates treatment of reduced PbtO2 episodes potentially conferring survival and outcome advantages in severe traumatic brain injury (TBI). To date, the nature and effectiveness of commonly used interventions in correcting compromised PbtO2 in TBI remains unclear. We sought to identify the most common interventions used in episodes of compromised PbtO2 and to analyze which were effective. METHODS A retrospective 7-year review of consecutive severe TBI patients with a PbtO2 monitor was conducted in a Level I trauma center's intensive care unit or neurosurgical registry. Episodes of compromised PbtO2 (defined as <20 mm Hg for 0.25-4 hours) were identified, and clinical interventions conducted during these episodes were analyzed. Response to treatment was gauged on how rapidly (ΔT) PbtO2 normalized (>20 mm Hg) and how great the PbtO2 increase was (ΔPbtO2). Intracranial pressure (ΔICP) and cerebral perfusion pressure (ΔCPP) also were examined for these episodes. RESULTS Six hundred twenty-five episodes of reduced PbtO2 were identified in 92 patients. Patient characteristics were: age 41.2 years, 77.2% men, and Injury Severity Score and head or neck Abbreviated Injury Scale score of 34.0 ± 9.2 and 4.9 ± 0.4, respectively. Five interventions: narcotics or sedation, pressors, repositioning, FIO2/PEEP increases, and combined sedation or narcotics + pressors were the most commonly used strategies. Increasing the number of interventions resulted in worsening the time to PbtO2 correction. Triple combinations resulted in the lowest ΔICP and dual combinations in the highest ΔCPP (p < 0.05). CONCLUSION Clinicians use a limited number of interventions when correcting compromised PbtO2. Using strategies employing many interventions administered closely together may be less effective in correcting PbO2, ICP, and CPP deficits. Some PbtO2 deficits may be self-limited.
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Vilalta A, Sahuquillo J, Merino MA, Poca MA, Garnacho A, Martínez-Valverde T, Dronavalli M. Normobaric hyperoxia in traumatic brain injury: does brain metabolic state influence the response to hyperoxic challenge? J Neurotrauma 2011; 28:1139-48. [PMID: 21534719 DOI: 10.1089/neu.2010.1720] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study sought to investigate whether normobaric hyperoxia (NH) improves brain oxygenation and brain metabolism in the early phase of severe and moderate traumatic brain injury (TBI) and whether this effect occurs uniformly in all TBI patients. Thirty patients (9 women and 21 men) with a median initial Glasgow Coma Score (GCS) of 6 (range, 3-12) were monitored using a brain microdialysis (MD) catheter with a brain tissue oxygen sensor (PtiO(2)) placed in the least-injured hemisphere. The inspired oxygen fraction was increased to 100% for 2 h. Patients were divided into two groups: Group 1: patients with baseline brain lactate ≤3 mmol/L and Group 2: patients with baseline brain lactate >3 mmol/L, and therefore increased anaerobic metabolism in the brain. In Group 1, no significant changes in brain metabolic parameters were found after hyperoxic challenge, whereas a significant increase in glucose and a decrease in the lactate-pyruvate ratio (LPR) were found in Group 2. In this latter group of patients, brain glucose increased on average by 17.9% (95% CI, +9.2% to +26.6%, p<0.001) and LPR decreased by 11.6% (95% CI, -16.2% to -6.9%, p<0.001). The results of our study show that moderate and severe TBI may induce metabolic alterations in the brain, even in macroscopically normal brain tissue. We observed that NH increased PaO(2) and PtiO(2) and significantly decreased LPR in patients in whom baseline brain lactate levels were increased, suggesting that NH improved the brain redox state. In patients with normal baseline brain lactate levels, we did not find any significant changes in the metabolic variables after NH. This suggests that the baseline metabolic state should be taken into account when applying NH to patients with TBI. This maneuver may only be effective in a specific group of patients.
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Affiliation(s)
- Anna Vilalta
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Paseo Vall d'Hebron 119-129, Barcelona, Spain
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