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Robba C, Messina A, Battaglini D, Ball L, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Cecconi M, Matta BF, Liu X, Rocco PRM, Czosnyka M, Pelosi P. Early Effects of Passive Leg-Raising Test, Fluid Challenge, and Norepinephrine on Cerebral Autoregulation and Oxygenation in COVID-19 Critically Ill Patients. Front Neurol 2021; 12:674466. [PMID: 34220684 PMCID: PMC8242251 DOI: 10.3389/fneur.2021.674466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) patients are at high risk of neurological complications consequent to several factors including persistent hypotension. There is a paucity of data on the effects of therapeutic interventions designed to optimize systemic hemodynamics on cerebral autoregulation (CA) in this group of patients. Methods: Single-center, observational prospective study conducted at San Martino Policlinico Hospital, Genoa, Italy, from October 1 to December 15, 2020. Mechanically ventilated COVID-19 patients, who had at least one episode of hypotension and received a passive leg raising (PLR) test, were included. They were then treated with fluid challenge (FC) and/or norepinephrine (NE), according to patients' clinical conditions, at different moments. The primary outcome was to assess the early effects of PLR test and of FC and NE [when clinically indicated to maintain adequate mean arterial pressure (MAP)] on CA (CA index) measured by transcranial Doppler (TCD). Secondary outcomes were to evaluate the effects of PLR test, FC, and NE on systemic hemodynamic variables, cerebral oxygenation (rSo2), and non-invasive intracranial pressure (nICP). Results: Twenty-three patients were included and underwent PLR test. Of these, 22 patients received FC and 14 were treated with NE. The median age was 62 years (interquartile range = 57-68.5 years), and 78% were male. PLR test led to a low CA index [58% (44-76.3%)]. FC and NE administration resulted in a CA index of 90.8% (74.2-100%) and 100% (100-100%), respectively. After PLR test, nICP based on pulsatility index and nICP based on flow velocity diastolic formula was increased [18.6 (17.7-19.6) vs. 19.3 (18.2-19.8) mm Hg, p = 0.009, and 12.9 (8.5-18) vs. 15 (10.5-19.7) mm Hg, p = 0.001, respectively]. PLR test, FC, and NE resulted in a significant increase in MAP and rSo2. Conclusions: In mechanically ventilated severe COVID-19 patients, PLR test adversely affects CA. An individualized strategy aimed at assessing both the hemodynamic and cerebral needs is warranted in patients at high risk of neurological complications.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Denise Battaglini
- San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Iole Brunetti
- San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Daniele R Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Nicolo' Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Basil F Matta
- Neurocritical Care Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Rio de Janeiro, Brazil
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
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