Effects of positive end-expiratory pressure ventilation on cerebral venous pressure with head elevation in dogs

Noninvasive and invasive mechanical ventilation for neurologic disorders

Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.

The impact of transesophageal echocardiography based protocol for management of adults in the sitting position on the incidence of clinically significant venous air embolism

The purpose of the study was to evaluate the impact of transesophageal echocardiography (TEE) – based protocol for management of adults in the sitting position during elective neurosurgical interventions on the incidence of clinically significant venous air embolism (VAE). Material and Methods ― The study involved 155 adult neurosurgery patients (70 in prospective group and 85 in retrospective group). Surgery in both groups was done in the sitting position. In the prospective group TEE-based protocol was used. Retrospective group served as control. The primary endpoint was considered to be a decrease in the frequency of clinically significant VAE in the prospective group in comparison with the retrospective one. In the prospective group, VAE with Tuebingen grade 3-5 was considered clinically significant. The PFO incidence and severity and the effect of the number of episodes of VAE per case on its maximum severity during surgery were also analyzed. Any complication in the postoperative period believed to be associated with the position of the patient on the table during the surgery was recorded. Results ― The incidence of the clinically significant VAE in the retrospective group was 23.5% (95% CI 15-34) and was 16.4% higher than the frequency in the prospective group (chi-square=7.6197, df=1, p=0.005). 50% (95% CI 38-62) of patients in prospective group developed VAE during surgery. In 16 cases, the number of episodes was more than one. The number of episodes of VAE in the observation was reliably associated with the maximum severity of VAE during the observation (Z=4.11; p<0.001). A moderate strength relationship was determined between them (SomersDelta=0.43; 95% CI 0.17-0.7). Not a single case of paradoxical air embolism was detected in a series of observations. None of the patients has got a neurological deficit or cardiopulmonary complications associated with the position on the surgical table in the postoperative period. Pneumocephalus was found in 100% of cases on head computed tomography, which, however, did not need surgical treatment. PFO in the prospective group was detected in 62% (95% CI 52-73) of patients. In 25% (95% CI 16-35), shunting was significant. A large PFO without Valsalva maneuver was detected in 12.5% (95% CI 6-21) of cases. Conclusion ― The use of the TEE-based protocol for the management of adult patients in a sitting position during elective neurosurgical interventions can reduce the incidence of clinically significant VAE.

Acute lung injury in patients with severe brain injury: a double hit model

The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.

Transient influence of end-tidal carbon dioxide tension on the postural restraint in cerebral perfusion

In the upright position, cerebral blood flow is reduced, maybe because arterial carbon dioxide partial pressure (PaCO2) decreases. We evaluated the time-dependent influence of a reduction in PaCO2, as indicated by the end-tidal Pco2 tension (PetCO2), on cerebral perfusion during head-up tilt. Mean arterial pressure, cardiac output, middle cerebral artery mean flow velocity (MCA Vmean), and dynamic cerebral autoregulation at supine rest and 70° head-up tilt were determined during free breathing and with PetCO2 clamped to the supine level. The postural changes in central hemodynamic variables were equivalent, and the cerebrovascular autoregulatory capacity was not significantly affected by tilt or by clamping PetCO2. In the first minute of tilt, the decline in MCA Vmean (10 ± 4 vs. 3 ± 4 cm/s; mean ± SE; P < 0.05) and PetCO2 (6.8 ± 4.3 vs. 1.7 ± 1.6 Torr; P < 0.05) was larger during spontaneous breathing than during isocapnic tilt. However, after 2 min in the head-up position, the reduction in MCA Vmean was similar (7 ± 5 vs. 6 ± 3 cm/s), although the spontaneous decline in PetCO2 was maintained ( P < 0.05 vs. isocapnic tilt). These results suggest that the potential contribution of PaCO2 to the postural reduction in MCA Vmean is transient, leaving the mechanisms for the sustained restrain in MCA Vmean to be identified.

Acute lung injury in patients with severe brain injury: a double hit model

The presence of pulmonary dysfunction after brain injury is well recognized. Acute lung injury (ALI) occurs in 20% of patients with isolated brain injury and is associated with a poor outcome. The "blast injury" theory, which proposes combined "hydrostatic" and "high permeability" mechanisms for the formation of neurogenic pulmonary edema, has been challenged recently by the observation that a systemic inflammatory response may play an integral role in the development of pulmonary dysfunction associated with brain injury. As a result of the primary cerebral injury, a systemic inflammatory reaction occurs, which induces an alteration in blood-brain barrier permeability and infiltration of activated neutrophils into the lung. This preclinical injury makes the lungs more susceptible to the mechanical stress of an injurious ventilatory strategy. Tight CO2 control is a therapeutic priority in patients with acute brain injury, but the use of high tidal volume ventilation may contribute to the development of ALI. Establishment of a therapeutic regimen that allows the combination of protective ventilation with the prevention of hypercapnia is, therefore, required. Moreover, in patients with brain injury, hypoxemia represents a secondary insult associated with a poor outcome. Optimal oxygenation may be achieved by using an adequate FiO2 and by application of positive end-expiratory pressure (PEEP). PEEP may, however, affect the cerebral circulation by hemodynamic and CO2-mediated mechanisms and the effects of PEEP on cerebral hemodynamics should be monitored in these patients and used to titrate its application.

A phase-contrast MRI study of physiologic cerebral venous flow

Although crucial in regulating intracranial hydrodynamics, the cerebral venous system has been rarely studied because of its structural complexity and individual variations. The purpose of our study was to evaluate the organization of cerebral venous system in healthy adults. Phase-contrast magnetic resonance imaging (PC-MRI) was performed in 18 healthy volunteers, in the supine position. Venous, arterial, and cerebrospinal fluid (CSF) flows were calculated. We found heterogeneous individual venous flows and variable side dominance in paired veins and sinuses. In some participants, the accessory epidural drainage preponderated over the habitually dominant jugular outflow. The PC-MRI enabled measurements of venous flows in superior sagittal (SSS), SRS (straight), and TS (transverse) sinuses with excellent detection rates. Pulsatility index for both intracranial (SSS) and cervical (mainly jugular) levels showed a significant increase in pulsatile blood flow in jugular veins as compared with that in SSS. Mean cervical and cerebral arterial blood flows were 714+/-124 and 649+/-178 mL/min, respectively. Cerebrospinal fluid aqueductal and cervical stroke volumes were 41+/-22 and 460+/-149 microL, respectively. Our results emphasize the variability of venous drainage for side dominance and jugular/epidural organization. The pulsatility of venous outflow and the role it plays in the regulation of intracranial pressure require further investigation.

Cerebral blood flow and metabolism during exercise: implications for fatigue

During exercise: the Kety-Schmidt-determined cerebral blood flow (CBF) does not change because the jugular vein is collapsed in the upright position. In contrast, when CBF is evaluated by 133Xe clearance, by flow in the internal carotid artery, or by flow velocity in basal cerebral arteries, a ∼25% increase is detected with a parallel increase in metabolism. During activation, an increase in cerebral O2 supply is required because there is no capillary recruitment within the brain and increased metabolism becomes dependent on an enhanced gradient for oxygen diffusion. During maximal whole body exercise, however, cerebral oxygenation decreases because of eventual arterial desaturation and marked hyperventilation-related hypocapnia of consequence for CBF. Reduced cerebral oxygenation affects recruitment of motor units, and supplemental O2 enhances cerebral oxygenation and work capacity without effects on muscle oxygenation. Also, the work of breathing and the increasing temperature of the brain during exercise are of importance for the development of so-called central fatigue. During prolonged exercise, the perceived exertion is related to accumulation of ammonia in the brain, and data support the theory that glycogen depletion in astrocytes limits the ability of the brain to accelerate its metabolism during activation. The release of interleukin-6 from the brain when exercise is prolonged may represent a signaling pathway in matching the metabolic response of the brain. Preliminary data suggest a coupling between the circulatory and metabolic perturbations in the brain during strenuous exercise and the ability of the brain to access slow-twitch muscle fiber populations.

Influence of upper body position on middle cerebral artery blood velocity during continuous positive airway pressure breathing

Continuous positive airway pressure (CPAP) is a treatment modality for pulmonary oxygenation difficulties. CPAP impairs venous return to the heart and, in turn, affects cerebral blood flow (CBF) and augments cerebral blood volume (CBV). We considered that during CPAP, elevation of the upper body would prevent a rise in CBV, while orthostasis would challenge CBF. To determine the body position least affecting indices of CBF and CBV, the middle cerebral artery mean blood velocity (MCA V(mean)) and the near-infrared spectroscopy determined frontal cerebral hemoglobin content (cHbT) were evaluated in 11 healthy subjects during CPAP at different body positions (15 degrees head-down tilt, supine, 15 degrees, 30 degrees and 45 degrees upper body elevation). In the supine position, 10 cmH(2)O of CPAP reduced MCA V(mean) by 9 +/- 3% and increased cHbT by 4 +/- 2 micromol/L (mean +/- SEM); (P < 0.05). In the head-down position, CPAP increased cHbT to 13 +/- 2 micromol/L but left MCA V(mean) unchanged. Upper body elevation by 15 degrees attenuated the CPAP associated reduction in MCA V(mean) (-7 +/- 2%), while cHbT returned to baseline (1 +/- 2 micromol/L). With larger elevation of the upper body MCA V(mean) decreased progressively to -17 +/- 3%, while cHbT remained unchanged from baseline. These results suggest that upper body elevation by approximately 15 degrees during 10 cmH(2)O CPAP prevents an increase in cerebral blood volume with minimal effect on cerebral blood flow.

Cerebro-pulmonary interactions during the application of low levels of positive end-expiratory pressure

OBJECTIVE

In patients with severe brain injury and acute lung injury the use of positive end-expiratory pressure (PEEP) is limited by conflicting results on its effect on intracranial pressure. We hypothesised that the occurrence of alveolar hyperinflation during the application of PEEP would lead to an increase in PaCO(2) responsible for a rise in intracranial pressure.

DESIGN

Prospective interventional study.

SETTING

Intensive Care Unit of University Hospitals.

PATIENTS AND PARTICIPANTS

Twelve severely brain-injured patients with acute lung injury and intracranial pressure higher than applied PEEP.

INTERVENTIONS

5 and 10 cmH(2)O of PEEP was randomly applied.

MEASUREMENTS AND RESULTS

In all patients intracranial pressure, flow velocity by transcranial Doppler of middle cerebral artery, and jugular oxygen saturation were recorded. Static volume-pressure curves of the respiratory system were obtained, recruited volume and elastance calculated to classify patients as recruiters and non-recruiters. In recruiters (= 6 patients), elastance decreased (P<0.01) and PaO(2) increased (P<0.005), while in non-recruiters (= 6 patients) elastance and PaCO(2) significantly increased (P<0.001). Intracranial pressure, Doppler flow velocity, and jugular saturation remained constant in recruiters but significantly increased (P<0.0001) in non-recruiters. A significant correlation was found between changes in intracranial pressure and elastance (r(2) = 0.8 P<0.0001) and between changes in PaCO(2) and intracranial pressure (P<0.001, r(2) = 0.4) and elastance (P<0.001, r(2) = 0.4), respectively.

CONCLUSIONS

When PEEP induced alveolar hyperinflation leading to a significant increase in PaCO(2), intracranial pressure significantly increased, whereas when PEEP caused alveolar recruitment intracranial pressure did not change.

Standing up to the challenge of standing: a siphon does not support cerebral blood flow in humans

Model studies have been advanced to suggest both that a siphon does and does not support cerebral blood flow in an upright position. If a siphon is established with the head raised, it would mean that internal jugular pressure reflects right atrium pressure minus the hydrostatic difference from the brain. This study measured spinal fluid pressure in the upright position, the pressure and the ultrasound-determined size of the internal jugular vein in the supine and sitting positions, and the internal jugular venous pressure during seated exercise. When the head was elevated ∼25 cm above the level of the heart, internal jugular venous pressure decreased from 9.5 (SD 2.8) to 0.2 (SD 1.0) mmHg [ n = 15; values are means (SD); P < 0.01]. Similarly, central venous pressure decreased from 6.2 (SD 1.8) to 0.6 (SD 2.6) mmHg ( P < 0.05). No apparent lumen was detected in any of the 31 left or right internal veins imaged at 40° head-up tilt, and submaximal ( n = 7) and maximal exercise ( n = 4) did not significantly affect internal jugular venous pressure. While seven subjects were sitting up, spinal fluid pressure at the lumbar level was 26 (SD 4) mmHg corresponding to 0.1 (SD 4.1) mmHg at the base of the brain. These results demonstrate that both for venous outflow from the brain and for spinal fluid, the prevailing pressure approaches zero at the base of the brain when humans are upright, which negates that a siphon supports cerebral blood flow.

Human cerebral venous outflow pathway depends on posture and central venous pressure

Internal jugular veins are the major cerebral venous outflow pathway in supine humans. In upright humans the positioning of these veins above heart level causes them to collapse. An alternative cerebral outflow pathway is the vertebral venous plexus. We set out to determine the effect of posture and central venous pressure (CVP) on the distribution of cerebral outflow over the internal jugular veins and the vertebral plexus, using a mathematical model. Input to the model was a data set of beat-to-beat cerebral blood flow velocity and CVP measurements in 10 healthy subjects, during baseline rest and a Valsalva manoeuvre in the supine and standing position. The model, consisting of 2 jugular veins, each a chain of 10 units containing nonlinear resistances and capacitors, and a vertebral plexus containing a resistance, showed blood flow mainly through the internal jugular veins in the supine position, but mainly through the vertebral plexus in the upright position. A Valsalva manoeuvre while standing completely re-opened the jugular veins. Results of ultrasound imaging of the right internal jugular vein cross-sectional area at the level of the laryngeal prominence in six healthy subjects, before and during a Valsalva manoeuvre in both body positions, correlate highly with model simulation of the jugular cross-sectional area (R(2) = 0.97). The results suggest that the cerebral venous flow distribution depends on posture and CVP: in supine humans the internal jugular veins are the primary pathway. The internal jugular veins are collapsed in the standing position and blood is shunted to an alternative venous pathway, but a marked increase in CVP while standing completely re-opens the jugular veins.

Expiratory pharyngeal airway obstruction during sleep: a multiple element model

OBJECTIVE/HYPOTHESIS

In patients with obstructive sleep apnea and snoring, airway obstruction during sleep is not limited to inspiration but may also occur with expiration. The aim of this study was to assess the segmental mechanics of expiratory obstruction.

DESIGN

Experimental study of a convenience sample of 20 patients with snoring and mild obstructive sleep apnea.

METHODS

During sedated sleep, airflow, airway pressure measurements (supraglottic, oropharyngeal, nasopharyngeal, and nasal mask), and either supraglottic/retroglossal or retropalatal areas were simultaneously measured. Nasal continuous positive airway pressures were experimentally adjusted during single breath tests (SBTs) to modify upper airway size. Airway mechanics were evaluated during pressure drops on expiration.

RESULTS

The predominant level of expiratory obstruction was supraglottic/retroglossal level alone (65%) or combined supraglottic/retroglossal and retropalatal (17.6%). In nonobstructed SBTs, compliance curves derived from supraglottic/retroglossal and retropalatal pressures were similar but diverged in obstructed breaths. Compliance during expiration was greater in the supraglottic/retroglossal segment compared to the retropalatal segment. Retropalatal cross-sectional size was smaller during early and late expiration on obstructed than on nonobstructed breaths independent of airway pressure measures. The rate of expiratory collapse was increased at all time points measured (P <.005) in the retropalatal segment on obstructed as compared with nonobstructed breaths.

CONCLUSIONS

During expiration, the supraglottic/retroglossal level is obstructed more frequently and has greater compliance than the retropalatal segment. Failure of upstream pressures to describe pharyngeal obstruction supports a multi-element model of collapse. Segments interact during expiration, with increased retropalatal collapse on obstructed as compared with nonobstructed breaths. Increased collapse on expiration provides a mechanism for increased obstruction on subsequent inspiratory breaths.

Middle cerebral artery blood velocity during intense static exercise is dominated by a Valsalva maneuver

Lifting of a heavy weight may lead to "blackout" and occasionally also to cerebral hemorrhage, indicating pronounced consequences for the blood flow through the brain. We hypothesized that especially strenuous respiratory straining (a Valsalva-like maneuver) associated with intense static exercise would lead to a precipitous rise in mean arterial and central venous pressures and, in turn, influence the middle cerebral artery blood velocity (MCA V(mean)) as a noninvasive indicator of changes in cerebral blood flow. In 10 healthy subjects, MCA V(mean) was evaluated in response to maximal static two-legged exercise performed either with a concomitantly performed Valsalva maneuver or with continued ventilation and also during a Valsalva maneuver without associated exercise (n = 6). During static two-legged exercise, the largest rise for mean arterial pressure and MCA V(mean) was established at the onset of exercise performed with a Valsalva-like maneuver (by 42 +/- 5 mmHg and 31 +/- 3% vs. 22 +/- 6 mmHg and 25 +/- 6% with continued ventilation; P < 0.05). Profound reductions in MCA V(mean) were observed both after exercise with continued ventilation (-29 +/- 4% together with a reduction in the arterial CO(2) tension by -5 +/- 1 Torr) and during the maintained Valsalva maneuver (-21 +/- 3% together with an elevation in central venous pressure to 40 +/- 7 mmHg). Responses to performance of the Valsalva maneuver with and without exercise were similar, reflecting the deterministic importance of the Valsalva maneuver for the central and cerebral hemodynamic response to intense static exercise. Continued ventilation during intense static exercise may limit the initial rise in arterial pressure and may in turn reduce the risk of hemorrhage. On the other hand, blackout during and after intense static exercise may reflect a reduction in cerebral blood flow due to expiratory straining and/or hyperventilation.

Syncope, cerebral perfusion, and oxygenation

During standing, both the position of the cerebral circulation and the reductions in mean arterial pressure (MAP) and cardiac output challenge cerebral autoregulatory (CA) mechanisms. Syncope is most often associated with the upright position and can be provoked by any condition that jeopardizes cerebral blood flow (CBF) and regional cerebral tissue oxygenation (cO(2)Hb). Reflex (vasovagal) responses, cardiac arrhythmias, and autonomic failure are common causes. An important defense against a critical reduction in the central blood volume is that of muscle activity ("the muscle pump"), and if it is not applied even normal humans faint. Continuous tracking of CBF by transcranial Doppler-determined cerebral blood velocity (V(mean)) and near-infrared spectroscopy-determined cO(2)Hb contribute to understanding the cerebrovascular adjustments to postural stress; e.g., MAP does not necessarily reflect the cerebrovascular phenomena associated with (pre)syncope. CA may be interpreted as a frequency-dependent phenomenon with attenuated transfer of oscillations in MAP to V(mean) at low frequencies. The clinical implication is that CA does not respond to rapid changes in MAP; e.g., there is a transient fall in V(mean) on standing up and therefore a feeling of lightheadedness that even healthy humans sometimes experience. In subjects with recurrent vasovagal syncope, dynamic CA seems not different from that of healthy controls even during the last minutes before the syncope. Redistribution of cardiac output may affect cerebral perfusion by increased cerebral vascular resistance, supporting the view that cerebral perfusion depends on arterial inflow pressure provided that there is a sufficient cardiac output.

Blood flow velocities in the basal cerebral vein after head trauma: a prospective study in 82 patients

BACKGROUND AND PURPOSE

The authors' aim was to evaluate the time course of the basal vein's (BVR) mean flow velocity (VBVR) in patients after traumatic brain injury and its relation to intracranial pressure (ICP), cerebral perfusion pressure (CPP), and the clinical outcome.

METHODS

In 82 head-injured patients (13 women and 69 men, median age = 31 years, Glasgow Coma Score = 15 to 3), daily measurement of the basal cerebral vein's and the middle cerebral artery's (MCA) flow velocities and pulsatilities was performed during each patient's entire stay in the intensive care unit. No angle correction was performed. A computerized sonography system (SD 800, Philips, Irvine, CA) with a 2.0-MHz to 2.5-MHz transducer was used for all measurements. The Glasgow Outcome Score (GOS) was evaluated after 6 months.

RESULTS

During the study period, VBVR values on the side of trauma were higher in the patients with favorable outcomes (GOS = 4 and 5) compared to patients with unfavorable outcomes (GOS = 2 and 3). This was statistically significant on days 4, 6, 7, and 11 and was not observed in the mean flow velocity of the MCA (VMCA). VBVR values among the good-outcome group tended to exceed the normal mean flow velocity (9.1 cm/s), whereas the unfavorable-outcome group was below this level. A correlation between venous flow velocity or pulsatility and ICP or CPP was not observed.

CONCLUSIONS

Repetitive Doppler examination of the basal cerebral veins may add new aspects to the monitoring of head-injured patients.

Effects of body position on intracranial and cerebral perfusion pressures in isoflurane-anesthetized horses

Inhalant anesthetics may interfere with normal cerebrovascular autoregulation. It was, therefore, hypothesized that intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in isoflurane-anesthetized horses would be especially sensitive to body and head position because of the potential for large hydrostatic gradients between the brain and heart in this species. Anesthesia was induced and maintained in six clinically healthy, unmedicated geldings with 1.57% isoflurane in O(2); mechanical ventilation was used to maintain normocapnia. ICP was measured by using a subarachnoid strain-gauge transducer. Blood gases and carotid arterial, right atrial, and airway pressures were also measured. Five body positions were studied in semirandomized order: dorsal recumbency (DR) with head down (HD), DR with head level (HL), lateral recumbency (LR), sternal recumbency (SR) with HL, and SR with head up (HU). Data were analyzed by using paired t-tests. ICP and CPP values, respectively, are as follows (means +/- SD): 36 +/- 4 and 55 +/- 18 mmHg (DR-HD); 34 +/- 6 and 51 +/- 32 mmHg (DR-HL); 24 +/- 5 and 48 +/- 4 mmHg (LR); 19 +/- 11 and 87 +/- 12 mmHg (SR-HL); and -14 +/- 7 and 71 +/- 10 mmHg (SR-HU). Significant differences were found among all positions, except for SR-HL vs. LR. Significant increases in CPP were observed only in sternal positions. In conclusion, ICP in isoflurane-anesthetized horses changes inversely with the brain-to-heart hydrostatic gradient. DR may also cause increases in ICP, irrespective of head position.

Venous air emboli occur during release of positive end-expiratory pressure and repositioning after sitting position surgery

We studied the effect of positive end-expiratory pressure (PEEP) release and positioning on the occurrence of venous air embolism (VAE). Eighteen consecutive patients (8 women, 10 men; ASA grade I-III) undergoing neurosurgery in the sitting position were studied. After induction of anesthesia ventilation was controlled with a PEEP of 5 cm H(2)O in an oxygen-air gas mixture. A transesophageal echocardiographic (TEE) probe was inserted. Preoperatively, a patent foramen ovale was excluded in all patients. TEE monitoring was performed during surgery, during PEEP release at the end of surgery with the patient still in the sitting position, and during change of the patient position into the supine position. The severity of VAE was differentiated as follows: grade 1 = only microbubbles; grade 2 = microbubbles and decrease of end-tidal carbon dioxide partial pressure (PETCO(2)) by more than 1.5 mm Hg; grade 3 = microbubbles combined with a decrease of PETCO(2) by more than 1.5 mm Hg, and a decrease of mean arterial blood pressure by at least 20 mm Hg. During surgery, VAE with a grade of 1, 2 or 3 occurred in 7, 4, and 2 patients, respectively. After PEEP release, VAE of grades 1, 2, and 3 were observed in 7, 2, and 1 patients, respectively. During repositioning from sitting to supine position, VAE of grades 1, 2, and 3 was observed in 6, 1, and 1 patients, respectively. The patient with VAE grade 3 needed inotropic support until 2 h after surgery to maintain sufficient blood pressure. No patient showed any sign of paradoxical arterial embolism or cardiac dysfunction. We conclude that VAE occurs not only during surgery in the sitting position, but also with release of PEEP and during repositioning to the supine position.

IMPLICATIONS

This study shows that venous air embolism (VAE) occurs not only during surgery in the sitting position but also during positive end-expiratory pressure release and repositioning of the patient into the supine position. Continuous monitoring for VAE should be performed until the patient is returned to the supine position.

Neurologic deficits after cervical laminectomy in the prone position

New neurologic deficits are known to occur after spine surgery. We present four patients with cervical myeloradiculopathy who underwent cervical laminectomy, fusion, or both in the prone position, supported by chest rolls. Three patients were intubated and positioned while awake, whereas the fourth patient was positioned after induction. Surgeries were successfully carried out, except for transient episodes of relative hypotension intraoperatively. On recovery from anesthesia, all patients were noted to have new neurologic deficits. Immediate CT myelography or surgical reexploration was unremarkable. All patients improved gradually with administration of high-dose steroids and induction of hypertension. Use of the prone position with abdominal compression may compromise spinal cord perfusion and lead to spinal cord ischemia. The use of frames that prevent abdominal compression, as well as avoidance of perioperative arterial hypotension, is important in maintaining adequate spinal cord perfusion during and after decompressive spinal cord surgery.

Influence of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure in patients with acute stroke

BACKGROUND AND PURPOSE

We undertook this study to evaluate the influence of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in patients with acute stroke.

METHODS

A total of 20 ventilated patients of a neurological intensive care unit were examined under a protocol entailing variation of PEEP to 4, 8, 12, and 4 mm Hg; mean arterial blood pressure (MAP), ICP, heart rate, and mean velocity of the middle cerebral arteries (V(m) MCA) were recorded.

RESULTS

CPP significantly changed depending on the various PEEP levels. No significant differences in remaining parameters were evident. Three distinct reaction patterns of the parameters monitored were observed: (1) All parameters remained stable through the various PEEP levels (15 patients, 40 examinations). (2) Increase in PEEP resulted in a significant decrease of MAP, while V(m) MCA remained unchanged, indicating an intact cerebral autoregulation. A slight (statistically insignificant) increase in ICP, which was significantly related to the MAP changes, was evident (7 patients, 16 examinations). (3) Increase in PEEP resulted in a decrease of MAP and V(m) MCA; ICP remained unchanged or demonstrated a slight decline (3 patients, 6 examinations).

CONCLUSIONS

PEEP increase up to 12 mm Hg does not significantly influence ICP. The observed marked changes in CPP are mediated through the MAP. Thus, PEEP application should be safe, provided that MAP is maintained.

Neurologic Intensive Care Unit Catastrophes: Airway, Breathing, and Circulation

When a catastrophic change in a patient occurs during the treatment of an underlying neurologic illness, management must be initiated to prevent secondary organ injury as disease specific treatment begins. Patients should be intubated, ventilated, and perfused, regardless of disease etiology or subsequent specific treatment.