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Zhou H, Lin C, Liu J, Wang X. Continuous monitoring of brain perfusion by cerebral oximetry after spontaneous return of circulation in cardiac arrest: a case report. BMC Neurol 2022; 22:365. [PMID: 36138343 PMCID: PMC9494769 DOI: 10.1186/s12883-022-02880-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral resuscitation determines the prognosis for patients who have experienced sudden death, and brain protection is the focus of clinical treatment. Cerebral resuscitation depends on the timing and quality of cardiopulmonary resuscitation (CPR). At present, cerebral oxygen monitoring is used mainly to monitor the quality of external cardiac compression and provide a prognosis for the nervous system. However, after the return of autonomous circulation, it is necessary to conduct continuous monitoring to ensure measures are taken timeously since hemodynamic instability, brain edema, and other factors may cause occult brain injury, and invasive arterial pressure cannot represent cerebral perfusion. CASE PRESENTATION By using continuous cerebral oxygen monitoring after CPR and the return of spontaneous circulation, a patient who was witnessed to have experienced sudden death in the hospital was found to have insufficient cerebral perfusion; he underwent timely intra-aortic balloon counterpulsation to improve his hemodynamics and cerebral perfusion. The patient went on to achieve a good neurological prognosis. CONCLUSION Cerebral oxygen monitoring should be conducted throughout the treatment period; physicians should understand cerebral perfusion in real time and implement timely intervention measures to reduce occult brain injury and improve the neurological prognosis of patients.
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Affiliation(s)
- Heng Zhou
- Department of Emergency Medicine, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, 100049, Beijing, China
| | - Caiwei Lin
- Department of Emergency Medicine, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, 100049, Beijing, China
| | - Jiawei Liu
- Department of Emergency Medicine, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, 100049, Beijing, China
| | - Xudong Wang
- Department of Emergency Medicine, Aerospace Center Hospital, 15 Yuquan Road, Haidian District, 100049, Beijing, China.
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Caldas JR, Panerai RB, Bor-Seng-Shu E, Ferreira GSR, Camara L, Passos RH, Salinet AM, Azevedo DS, de-Lima-Oliveira M, Galas FRBG, Fukushima JT, Nogueira R, Taccone FS, Landoni G, Almeida JP, Robinson TG, Hajjar LA. Intra-aortic balloon pump does not influence cerebral hemodynamics and neurological outcomes in high-risk cardiac patients undergoing cardiac surgery: an analysis of the IABCS trial. Ann Intensive Care 2019; 9:130. [PMID: 31773324 PMCID: PMC6879692 DOI: 10.1186/s13613-019-0602-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/07/2019] [Indexed: 12/24/2022] Open
Abstract
Background The intra-aortic balloon pump (IABP) is often used in high-risk patients undergoing cardiac surgery to improve coronary perfusion and decrease afterload. The effects of the IABP on cerebral hemodynamics are unknown. We therefore assessed the effect of the IABP on cerebral hemodynamics and on neurological complications in patients undergoing cardiac surgery who were randomized to receive or not receive preoperative IABP in the ‘Intra-aortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery’ (IABCS) trial. Methods This is a prospectively planned analysis of the previously published IABCS trial. Patients undergoing elective coronary artery bypass surgery with ventricular ejection fraction ≤ 40% or EuroSCORE ≥ 6 received preoperative IABP (n = 90) or no IABP (n = 91). Cerebral blood flow velocity (CBFV) of the middle cerebral artery through transcranial Doppler and blood pressure through Finometer or intra-arterial line were recorded preoperatively (T1) and 24 h (T2) and 7 days after surgery (T3) in patients with preoperative IABP (n = 34) and without IABP (n = 33). Cerebral autoregulation was assessed by the autoregulation index that was estimated from the CBFV response to a step change in blood pressure derived by transfer function analysis. Delirium, stroke and cognitive decline 6 months after surgery were recorded. Results There were no differences between the IABP and control patients in the autoregulation index (T1: 5.5 ± 1.9 vs. 5.7 ± 1.7; T2: 4.0 ± 1.9 vs. 4.1 ± 1.6; T3: 5.7 ± 2.0 vs. 5.7 ± 1.6, p = 0.97) or CBFV (T1: 57.3 ± 19.4 vs. 59.3 ± 11.8; T2: 74.0 ± 21.6 vs. 74.7 ± 17.5; T3: 71.1 ± 21.3 vs. 68.1 ± 15.1 cm/s; p = 0.952) at all time points. Groups were not different regarding postoperative rates of delirium (26.5% vs. 24.2%, p = 0.83), stroke (3.0% vs. 2.9%, p = 1.00) or cognitive decline through analysis of the Mini-Mental State Examination (16.7% vs. 40.7%; p = 0.07) and Montreal Cognitive Assessment (79.16% vs. 81.5%; p = 1.00). Conclusions The preoperative use of the IABP in high-risk patients undergoing cardiac surgery did not affect cerebral hemodynamics and was not associated with a higher incidence of neurological complications. Trial registrationhttp://www.clinicaltrials.gov (NCT02143544).
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Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil.,Universidade de Salvador, UNIFACS, Salvador, Bahia, Brazil.,Critical Care Unit Hospital São Rafael Salvador, Salvador, Brazil.,Escola Bahiana de Medicina e Saude Púbica, Salvador, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Edson Bor-Seng-Shu
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | - Ligia Camara
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Rogério H Passos
- Critical Care Unit Hospital São Rafael Salvador, Salvador, Brazil
| | - Angela M Salinet
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Daniel S Azevedo
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | | | - Julia T Fukushima
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Ricardo Nogueira
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Fabio S Taccone
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University of Milan, Milan, Italy
| | - Juliano P Almeida
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Universidade de São Paulo, São Paulo, Brazil. .,Surgical Intensive Care, Heart Institute, University of São Paulo, Av. Dr. Ene´as de Carvalho Aguiar 44, 05403-000, São Paulo, Brazil.
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Bilirubin and Ischemic Stroke: Rendering the Current Paradigm to Better Understand the Protective Effects of Bilirubin. Mol Neurobiol 2019; 56:5483-5496. [PMID: 30612336 DOI: 10.1007/s12035-018-1440-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/21/2018] [Indexed: 01/14/2023]
Abstract
Novel and innovative methods are critical in fostering new treatments and improving clinical outcomes in patients who suffer from ischemic stroke. Bilirubin has long been considered metabolic waste that can be harmful to the body; however, it is now becoming recognized as one of the body's most potent antioxidant, anti-inflammatory, and neuroprotective molecules. These properties facilitate bilirubin's anti-atherogenic effects to impede and prevent the formation of thrombi in ischemic stroke. These functions allow for protection from neuronal injury during an ischemic state and suggest that elevated bilirubin levels may be linked to a lower rate of morbidity and mortality. Therefore, here we discuss the pathophysiology of stroke and the molecular properties of bilirubin to better understand their beneficial relationship. We outline clinical studies looking at the relationship between serum bilirubin levels and ischemic stroke prevalence. At this time, few studies have rigorously looked at the relationship between bilirubin and ischemic stroke, whether it is positive or negative. Thus, rigorous research is needed to provide evidence supporting the current studies, expand on these studies, and facilitate their translation to bedside therapy for patients who suffer from ischemic stroke.
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Unilateral Headache Status after Intra-Aortic Balloon Pump Placement. Case Rep Med 2017; 2017:5043471. [PMID: 28819361 PMCID: PMC5551466 DOI: 10.1155/2017/5043471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/02/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Intra-aortic balloon pump (IABP) counterpulsation is a catheter-based treatment for coronary artery disease and decompensated heart failure to increase coronary blood flow and improve cardiac output. IABP is generally well tolerated, and complications are usually related to peripheral vasculature or red blood cell and platelet consumption. The usual insertion site via femoral artery renders the patient bedbound. Recently, axillary artery has been used in patients with atherosclerotic peripheral vascular disease and documented small arteries or in those awaiting transplant to ensure ambulation and prevent deconditioning. Case Report We present a patient with ischemic cardiomyopathy and severe left ventricular dysfunction, awaiting Orthotropic Heart Transplant. His worsening intractable angina and dyspnea necessitated IABP placement via left axillary artery, significantly improving his condition. He subsequently experienced migraine-type persistent unilateral headache refractory to standard pain management. Multiple strategies were utilized to treat his pain, but the patient insisted that his pain commenced after IABP placement. Ultimately, the removal of the pump led to complete resolution with no recurrence. Conclusion The authors hypothesize that the unilaterally directed blood flow and direct increase in cerebral perfusion from the intra-aortic balloon pump may have caused vasodilation of the extracranial arteries, leading to a persistent and debilitating headache in this susceptible patient.
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Caldas JR, Panerai RB, Bor-Seng-Shu E, Almeida JP, Ferreira GSR, Camara L, Nogueira RC, Oliveira ML, Jatene FB, Robinson TG, Hajjar LA. Cerebral hemodynamics with intra-aortic balloon pump: business as usual? Physiol Meas 2017; 38:1349-1361. [PMID: 28333037 DOI: 10.1088/1361-6579/aa68c4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Intra-aortic balloon pump (IABP) is commonly used as mechanical support after cardiac surgery or cardiac shock. Although its benefits for cardiac function have been well documented, its effects on cerebral circulation are still controversial. We hypothesized that transfer function analysis (TFA) and continuous estimates of dynamic cerebral autoregulation (CA) provide consistent results in the assessment of cerebral autoregulation in patients with IABP. APPROACH Continuous recordings of blood pressure (BP, intra-arterial line), end-tidal CO2, heart rate and cerebral blood flow velocity (CBFV, transcranial Doppler) were obtained (i) 5 min with IABP ratio 1:3, (ii) 5 min, starting 1 min with the IABP-ON, and continuing for another 4 min without pump assistance (IABP-OFF). Autoregulation index (ARI) was estimated from the CBFV response to a step change in BP derived by TFA and as a function of time using an autoregressive moving-average model during removal of the device (ARI t ). Critical closing pressure and resistance area-product were also obtained. MAIN RESULTS ARI with IABP-ON (4.3 ± 1.2) were not different from corresponding values at IABP-OFF (4.7 ± 1.4, p = 0.42). Removal of the balloon had no effect on ARI t , CBFV, BP, cerebral critical closing pressure or resistance area-product. SIGNIFICANCE IABP does not disturb cerebral hemodynamics. TFA and continuous estimates of dynamic CA can be used to assess cerebral hemodynamics in patients with IABP. These findings have important implications for the design of studies of critically ill patients requiring the use of different invasive support devices.
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Affiliation(s)
- J R Caldas
- Department of Anesthesia, University of São Paulo, São Paulo, Brazil. Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
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Abstract
In the setting of mechanical circulatory support devices, including ventricular assist devices, extracorporeal membrane oxygenation, intraaortic balloon pumps, and the total artificial heart, the spectral Doppler waveform is significantly altered, reflecting systemic hemodynamic changes. As the prevalence of these devices increases, a better understanding of both the devices themselves and their associated Doppler ultrasound findings is necessary for accurate image interpretation. This article reviews the clinical indications, pathophysiology, and sonographic findings of these devices, with emphasis on the variation in arterial Doppler waveforms that can be seen with normal function, as well as the major complications.
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Kaufmann TAS, Neidlin M, Büsen M, Sonntag SJ, Steinseifer U. Implementation of intrinsic lumped parameter modeling into computational fluid dynamics studies of cardiopulmonary bypass. J Biomech 2013; 47:729-35. [PMID: 24365093 DOI: 10.1016/j.jbiomech.2013.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 11/20/2022]
Abstract
Stroke and cerebral hypoxia are among the main complications during cardiopulmonary bypass (CPB). The two main reasons for these complications are the cannula jet, due to altered flow conditions and the sandblast effect, and impaired cerebral autoregulation which often occurs in the elderly. The effect of autoregulation has so far mainly been modeled using lumped parameter modeling, while Computational Fluid Dynamics (CFD) has been applied to analyze flow conditions during CPB. In this study, we combine both modeling techniques to analyze the effect of lumped parameter modeling on blood flow during CPB. Additionally, cerebral autoregulation is implemented using the Baroreflex, which adapts the cerebrovascular resistance and compliance based on the cerebral perfusion pressure. The results show that while a combination of CFD and lumped parameter modeling without autoregulation delivers feasible results for physiological flow conditions, it overestimates the loss of cerebral blood flow during CPB. This is counteracted by the Baroreflex, which restores the cerebral blood flow to native levels. However, the cerebral blood flow during CPB is typically reduced by 10-20% in the clinic. This indicates that either the Baroreflex is not fully functional during CPB, or that the target value for the Baroreflex is not a full native cerebral blood flow, but the plateau phase of cerebral autoregulation, which starts at approximately 80% of native flow.
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Affiliation(s)
- Tim A S Kaufmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany.
| | - Michael Neidlin
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Martin Büsen
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Simon J Sonntag
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
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Kaufmann TA, Schmitz-Rode T, Steinseifer U. Implementation of Cerebral Autoregulation Into Computational Fluid Dynamics Studies of Cardiopulmonary Bypass. Artif Organs 2012; 36:754-8. [DOI: 10.1111/j.1525-1594.2012.01519.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kaufmann TA, Wong KC, Schmitz-Rode T, Steinseifer U. Mimicking of Cerebral Autoregulation by Flow-Dependent Cerebrovascular Resistance: A Feasibility Study. Artif Organs 2012; 36:E97-101. [DOI: 10.1111/j.1525-1594.2011.01433.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Munir MB, Jiang J, Mehdi MJ, Takayama H, Cheema FH. A novel subcutaneous counterpulsation device: acute hemodynamic efficacy during pharmacologically induced hypertension, hypotension, and heart failure. Artif Organs 2011; 35:92-3; author reply 93-5. [PMID: 21226745 DOI: 10.1111/j.1525-1594.2010.01176.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Laumen M, Kaufmann T, Timms D, Schlanstein P, Jansen S, Gregory S, Wong KC, Schmitz-Rode T, Steinseifer U. Flow Analysis of Ventricular Assist Device Inflow and Outflow Cannula Positioning Using a Naturally Shaped Ventricle and Aortic Branch. Artif Organs 2010; 34:798-806. [DOI: 10.1111/j.1525-1594.2010.01098.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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