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Bhandari C, Gandhi H, Panwar A, Haranal M, Pandya H. Prospective Randomized Pilot Trial on the Effects of Mild Hypercapnia on Cerebral Oxygen Saturation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2024; 38:1322-1327. [PMID: 38523024 DOI: 10.1053/j.jvca.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/15/2024] [Accepted: 02/25/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE AND DESIGN A single-center prospective randomized controlled study was conducted to assess the effect of targeted mild hypercapnia (TMH) on cerebral oxygen saturation (rSO2) in patients undergoing off-pump coronary artery bypass grafting (CABG). SETTING AND PARTICIPANTS A prospective randomized controlled study involving 100 patients undergoing off-pump CABG at U. N. Mehta Hospital, Ahmedabad, Gujarat, India. INTERVENTION Patients were randomized to either the TMH (PaCO2 45-55 mmHg) or the targeted normocapnia (TN; PaCO2 35-45 mmHg) group, containing 50 patients in each group. MEASUREMENTS Monitoring of rSO2, heart rate, mean arterial pressure (MAP), PaCO2, and peripheral oxygen saturation was done at baseline, after induction, after left internal mammary artery harvesting, at each grafting (distal and proximal), after protamine, and after shifting to the intensive care unit. The standardized minimental-state examination (SMMSE) was performed preoperatively and at 8, 12, and 24 hours postextubation. Data were analyzed using an independent sample t test. RESULTS The TMH group had higher MAP during grafting (p < 0.001) and higher rSO2 on both sides during distal and proximal grafting (p < 0.001) and after protamine (p < 0.05), as compared to the TN group. Compared to preoperative values, SMMSE scores in the TN group were significantly lower at 12 and 24 hours postextubation (p < 0.001). CONCLUSION TMH during grafting increased the cerebral blood flow and rSO2 when hemodynamic instability was very common. It has a protective role on the brain and helps maintain cognition postoperatively.
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Affiliation(s)
- Chanchal Bhandari
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (affiliated with B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad.
| | - Hemang Gandhi
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (affiliated with B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad
| | - Anil Panwar
- Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Center (affiliated with B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad
| | - Maruti Haranal
- Department CVTS, U. N. Mehta Institute of Cardiology and Research Center (affiliated with B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad
| | - Himani Pandya
- Department of Research, U. N. Mehta Institute of Cardiology and Research Center (affiliated with B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad
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Lei L, Wu Y, Chen W, Chen M, Liu Q, Chen W, Lin Q. Two-lung ventilation with artificial pneumothorax on cerebral desaturation and early postoperative cognitive outcome: a randomized controlled trial. Surg Endosc 2024; 38:2709-2718. [PMID: 38528264 DOI: 10.1007/s00464-024-10786-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The effect of two lung ventilation (TLV) with carbon dioxide artificial pneumothorax on cerebral desaturation and postoperative neurocognitive changes in elderly patients undergoing elective minimally invasive esophagectomy (MIE) is unclear. OBJECTIVES The first aim of this study was to compare the effect of TLV and one lung ventilation (OLV) on cerebral desaturation. The second aim was to assess changes in early postoperative cognitive outcomes of two ventilation methods. METHODS This prospective, randomized, controlled trial enrolled patients 65 and older scheduled for MIE. Patients were randomly assigned (1:1) to TLV group or OLV group. The primary outcome was the incidence of cerebral desaturation events (CDE). Secondary outcomes were the cumulative area under the curve of desaturation for decreases in regional cerebral oxygen saturation (rSO2) values below 20% relative to the baseline value (AUC.20) and the incidence of delayed neurocognitive recovery. RESULTS Fifty-six patients were recruited between November 2019 and August 2020. TLV group had a lower incidence of CDE than OLV group [3 (10.71%) vs. 13 (48.14%), P = 0.002]. TLV group had a lower AUC.20 [0 (0-35.86) % min vs. 0 (0-0) % min, P = 0.007], and the incidence of delayed neurocognitive recovery [2 (7.4%) vs. 11 (40.7%), P = 0.009] than OLV group. Predictors of delayed neurocognitive recovery on postoperative day 7 were age (OR 1.676, 95% CI 1.122 to 2.505, P = 0.006) and AUC.20 (OR 1.059, 95% CI 1.025 to 1.094, P < 0.001). CONCLUSION Compared to OLV, TLV had a lower incidence of CDE and delayed neurocognitive recovery in elderly patients undergoing MIE. The method of TLV combined with carbon dioxide artificial pneumothorax may be an option for these elderly patients. Chinese Clinical Trial Registry (identifier: ChiCTR1900027454).
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Affiliation(s)
- Lihua Lei
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Yanlin Wu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Wencong Chen
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, 37201, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, 37201, USA
| | - Min Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Qiaoping Liu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Wenshu Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Qun Lin
- Department of Anesthesiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, Fujian, China.
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Li Z, Zhu Y, Qin S, Gao X, Kang Y, Li S, Chai J. Effects of permissive hypercapnia on intraoperative cerebral oxygenation and early postoperative cognitive function in older patients with non-acute fragile brain function undergoing laparoscopic colorectal surgery: protocol study. BMC Geriatr 2023; 23:581. [PMID: 37735369 PMCID: PMC10512528 DOI: 10.1186/s12877-023-04125-4] [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: 10/24/2022] [Accepted: 06/21/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Perioperative brain protection in older patients has been the focus of research recently; meanwhile, exploring the relationship between regional cerebral oxygen saturation (rSO2) and brain function in the perioperative period has been an emerging and challenging area-the difficulties related to the real-time monitoring of rSO2 and the choice of feasible interventions. As an advanced instrument for intraoperative rSO2 monitoring, the clinical application of near-infrared spectrum (NIRS) cerebral oxygen monitoring has gradually increased in popularity and is being recognized for its beneficial clinical outcomes in patients undergoing cardiac and noncardiac surgery. In addition, although sufficient evidence to support this hypothesis is still lacking, the effect of permissive hypercapnia (PHC) on rSO2 has expanded from basic research to clinical exploration. Therefore, monitoring intraoperative rSO2 in older patients with NIRS technology and exploring possible interventions that may change rSO2 and even improve postoperative cognitive performance is significant and clinically valuable. METHODS This study is a single-center randomized controlled trial (RCT). 76 older patients are enrolled as subjects. Patients who meet the screening criteria will be randomly assigned 1:1 to the control and intervention groups. PHC-based mechanical ventilation will be regarded as an intervention. The primary outcome is the absolute change in the percent change in rSO2 from baseline to the completion of surgery in the intervention and control groups. Secondary outcomes mainly include observations of intraoperative cerebral oxygenation and metabolism, markers of brain injury, and assessments of patients' cognitive function using scale through postoperative follow-up. DISCUSSION The findings of this RCT will reveal the effect of PHC on intraoperative rSO2 in older patients with nonacute fragile brain function (NFBF) and the approximate trends over time, and differences in postoperative cognitive function outcomes. We anticipate that the trial results will inform clinical policy decision-makers in clinical practice, enhance the management of intraoperative cerebral oxygen monitoring in older patients with comorbid NFBF, and provide guidance for clinical brain protection and improved postoperative cognitive function outcomes. TRIAL REGISTRATION ChiCTR, ChiCTR2200062093, Registered 9/15/2022.
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Affiliation(s)
- Zhichao Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shangyuan Qin
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Xin Gao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yihan Kang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Si Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun Chai
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China.
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Ahrens E, Tartler TM, Suleiman A, Wachtendorf LJ, Ma H, Chen G, Kendale SM, Kienbaum P, Subramaniam B, Wagner S, Schaefer MS. Dose-dependent relationship between intra-procedural hypoxaemia or hypocapnia and postoperative delirium in older patients. Br J Anaesth 2023; 130:e298-e306. [PMID: 36192221 DOI: 10.1016/j.bja.2022.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Previous studies indicated an association between impaired cerebral perfusion and post-procedural neurological disorders. We investigated whether intra-procedural hypoxaemia or hypocapnia are associated with delirium after surgery. METHODS Inpatients ≥60 yr of age undergoing anaesthesia for surgical or interventional procedures between 2009 and 2020 at an academic healthcare network in the USA (Massachusetts) were included in this hospital registry study. The primary exposure was intra-procedural hypoxaemia, defined as peripheral oxygen saturation <90% for >2 cohering min. The co-primary exposure was hypocapnia during general anaesthesia, defined as end-tidal carbon dioxide pressure ≤25 mm Hg for >5 cohering min. The primary outcome was delirium within 7 days after surgery. RESULTS Of 71 717 included patients, 1702 (2.4%) developed postoperative delirium, and hypoxaemia was detected in 2532 (3.5%). Of 42 894 patients undergoing general anaesthesia, 532 (1.2%) experienced hypocapnia. The occurrence of either hypoxaemia (adjusted odds ratio [ORadj]=1.71; 95% confidence interval [CI], 1.40-2.07; P<0.001) or hypocapnia (ORadj=1.77; 95% CI, 1.30-2.41; P<0.001) was associated with a higher risk of delirium within 7 days. Both associations were dependent on the magnitude, and increased with event duration (ORadj=1.03; 95% CI, 1.02-1.04; P<0.001 and ORadj=1.01; 95% CI, 1.00-1.01; P=0.005, for each minute increase in the longest continuous episode, respectively). There was no association between occurrence of hypercapnia and postoperative delirium (ORadj=1.24; 95% CI, 0.90-1.71; P=0.181). CONCLUSIONS Intra-procedural hypoxaemia and hypocapnia were dose-dependently associated with a higher risk of postoperative delirium. These findings support maintaining normal gas exchange to avoid postoperative neurological disorders.
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Affiliation(s)
- Elena Ahrens
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE) Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tim M Tartler
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE) Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aiman Suleiman
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE) Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Luca J Wachtendorf
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE) Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Haobo Ma
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Guanqing Chen
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE) Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samir M Kendale
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Peter Kienbaum
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Balachundhar Subramaniam
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Sadhguru Center for a Conscious Planet, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Soeren Wagner
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Klinikum Rechts der Isar, Munich, Germany; Department of Anesthesiology, Katharinenhospital Klinikum Stuttgart, Stuttgart, Germany
| | - Maximilian S Schaefer
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE) Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany.
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Neuroprotective Role of Acidosis in Ischemia: Review of the Preclinical Evidence. Mol Neurobiol 2021; 58:6684-6696. [PMID: 34606050 DOI: 10.1007/s12035-021-02578-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 09/26/2021] [Indexed: 12/09/2022]
Abstract
Efforts to develop effective neuroprotective therapies for ischemic stroke have had little success to date. One promising approach to neuroprotection is ischemic postconditioning, which utilizes brief bouts of ischemia after acute ischemic stroke to elicit neuroprotection, although the mechanism is largely unknown. As the primary components of transient ischemia are local hypoxia and acidosis, and hypoxic postconditioning has had little success, it is possible that the acidosis component may be the primary driver. To address the evidence behind this, we performed a systematic review of preclinical studies focused on the neuroprotective role of transient acidosis after ischemia. Animal studies demonstrated that mild-to-moderate acidosis after ischemic events led to better functional neurologic outcomes with reduced infarct volumes, while severe acidosis often led to cerebral edema and worse functional outcomes. In vitro studies demonstrated that mild-to-moderate acidosis improves neuronal survival largely through two means: (1) inhibition of harmful superoxide formation in the excitotoxic pathway and (2) remodeling neuronal mitochondria to allow for efficient ATP production (i.e., oxidative phosphorylation), even in the absence of oxygen. Similar to the animal studies, acidotic postconditioning in humans would entail short cycles of carbon dioxide inhalation, which has already been demonstrated to be safe as part of a hypercapnic challenge when measuring cerebrovascular reactivity. Due to the preclinical efficacy of acidotic postconditioning, its relatively straightforward translation into humans, and the growing need for neuroprotective therapies, future preclinical studies should focus on filling the current knowledge gaps that are currently restricting the development of phase I/II clinical trials.
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Optimal Targets of the First 24-h Partial Pressure of Carbon Dioxide in Patients with Cerebral Injury: Data from the MIMIC-III and IV Database. Neurocrit Care 2021; 36:412-420. [PMID: 34331211 DOI: 10.1007/s12028-021-01312-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND It is generally believed that hypercapnia and hypocapnia will cause secondary injury to patients with craniocerebral diseases, but a small number of studies have shown that they may have potential benefits. We assessed the impact of partial pressure of arterial carbon dioxide (PaCO2) on in-hospital mortality of patients with craniocerebral diseases. The hypothesis of this research was that there is a nonlinear correlation between PaCO2 and in-hospital mortality in patients with craniocerebral diseases and that mortality rate is the lowest when PaCO2 is in a normal range. METHODS We identified patients with craniocerebral diseases from Medical Information Mart for Intensive Care third and fourth edition databases. Cox regression analysis and restricted cubic splines were used to examine the association between PaCO2 and in-hospital mortality. RESULTS Nine thousand six hundred and sixty patients were identified. A U-shaped association was found between the first 24-h PaCO2 and in-hospital mortality in all participants. The nadir for in-hospital mortality risk was estimated to be at 39.5 mm Hg (p for nonlinearity < 0.001). In the subsequent subgroup analysis, similar results were found in patients with traumatic brain injury, metabolic or toxic encephalopathy, subarachnoid hemorrhage, cerebral infarction, and other encephalopathies. Besides, the mortality risk reached a nadir at PaCO2 in the range of 35-45 mm Hg. The restricted cubic splines showed a U-shaped association between the first 24-h PaCO2 and in-hospital mortality in patients with other intracerebral hemorrhage and cerebral tumor. Nonetheless, nonlinearity tests were not statistically significant. In addition, Cox regression analysis showed that PaCO2 ranging 35-45 mm Hg had the lowest death risk in most patients. For patients with hypoxic-ischemic encephalopathy and intracranial infections, the first 24-h PaCO2 and in-hospital mortality did not seem to be correlated. CONCLUSIONS Both hypercapnia and hypocapnia are harmful to most patients with craniocerebral diseases. Keeping the first 24-h PaCO2 in the normal range (35-45 mm Hg) is associated with lower death risk.
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Abstract
Carbon dioxide is a common gas in the air which has been widely used in medical treatment. A carbon dioxide molecule consists of two oxygen atoms and one carbon atom through a covalent bond. In the body, carbon dioxide reacts with water to produce carbonic acid. In healthy people, carbon dioxide is maintained within a narrow range (35–45 mmHg) by physiological mechanisms. The role of hypocapnia (partial pressure of carbon dioxide < 35 mmHg) and hypercapnia (partial pressure of carbon dioxide > 45 mmHg) in the nervous system is intricate. Past researches mainly focus on the effect of hypocapnia to nerve protection. Nevertheless, Hypercapnia seems to play an important role in neuroprotection. The mechanisms of hypocapnia and hypercapnia in the nervous system deserve our attention. The purpose of this review is to summarize the effect of hypocapnia and hypercapnia in stroke and traumatic brain injury.
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Affiliation(s)
- Ru-Ming Deng
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Yong-Chun Liu
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jin-Quan Li
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jian-Guo Xu
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Gang Chen
- Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Giannakis S, Ruhfus M, Markus M, Stein A, Hoehn T, Felderhoff-Mueser U, Sabir H. Mechanical Ventilation, Partial Pressure of Carbon Dioxide, Increased Fraction of Inspired Oxygen and the Increased Risk for Adverse Short-Term Outcomes in Cooled Asphyxiated Newborns. CHILDREN-BASEL 2021; 8:children8060430. [PMID: 34063852 PMCID: PMC8224013 DOI: 10.3390/children8060430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/04/2021] [Accepted: 05/18/2021] [Indexed: 11/26/2022]
Abstract
Neonates treated with therapeutic hypothermia (TH) following perinatal asphyxia (PA) suffer a considerable rate of disability and mortality. Several risk factors associated with adverse outcomes have been identified. Mechanical ventilation might increase the risk for hyperoxia and hypocapnia in cooled newborns. We carried out a retrospective study in 71 asphyxiated cooled newborns. We analyzed the association of ventilation status and adverse short-term outcomes and investigated the effect of the former on pCO2 and oxygen delivery before, during and after TH. Death, abnormal findings on magnetic resonance imaging, and pathological amplitude-integrated electroencephalography traces were used to define short-term outcomes. The need for mechanical ventilation was significantly higher in the newborns with adverse outcomes (38% vs. 5.6%, p = 0.001). Compared to spontaneously breathing neonates, intubated newborns suffered from significantly more severe asphyxia, had significantly lower levels of mean minimum pCO2 over the first 6 and 72 h of life (HOL) (p = 0.03 and p = 0.01, respectively) and increased supply of inspired oxygen, which was, in turn, significantly higher in the newborns with adverse outcomes (p < 0.01). Intubated newborns with adverse short-term outcomes had lower levels of pCO2 over the first 36 HOL. In conclusion, need for mechanical ventilation was significantly higher in newborns with more severe asphyxia. In ventilated newborns, level of encephalopathy, lower pCO2 levels, and increased oxygen supplementation were significantly higher in the adverse short-term outcomes group. Ventilatory parameters need to be carefully monitored in cooled asphyxiated newborns.
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Affiliation(s)
- Stamatios Giannakis
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Faculty of Medicine, University Children’s Hospital, Heinrich-Heine-University Duesseldorf, 40225 Düsseldorf, Germany; (S.G.); (M.M.); (T.H.)
| | - Maria Ruhfus
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Mona Markus
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Faculty of Medicine, University Children’s Hospital, Heinrich-Heine-University Duesseldorf, 40225 Düsseldorf, Germany; (S.G.); (M.M.); (T.H.)
| | - Anja Stein
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Thomas Hoehn
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Faculty of Medicine, University Children’s Hospital, Heinrich-Heine-University Duesseldorf, 40225 Düsseldorf, Germany; (S.G.); (M.M.); (T.H.)
| | - Ursula Felderhoff-Mueser
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
| | - Hemmen Sabir
- Department of Pediatrics I/Neonatology, University Hospital Essen, University Duisburg Essen, 45147 Essen, Germany; (M.R.); (A.S.); (U.F.-M.)
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital University of Bonn, 53127 Bonn, Germany
- German Centre for Neurodegenerative Diseases (DZNE), 53127 Bonn, Germany
- Correspondence:
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Abstract
Central nervous system injuries are a leading cause of death and disability worldwide. Although the exact pathophysiological mechanisms of various brain injuries vary, central nervous system injuries often result in an inflammatory response, and subsequently lead to brain damage. This suggests that neuroprotection may be necessany in the treatment of multiple disease models. The use of medical gases as neuroprotective agents has gained great attention in the medical field. Medical gases include common gases, such as oxygen, hydrogen and carbon dioxide; hydrogen sulphide and nitric oxide that have been considered toxic; volatile anesthetic gases, such as isoflurane and sevoflurane; and inert gases like helium, argon, and xenon. The neuroprotection from these medical gases has been investigated in experimental animal models of various types of brain injuries, such as traumatic brain injury, stroke, subarachnoid hemorrhage, cerebral ischemic/reperfusion injury, and neurodegenerative diseases. Nevertheless, the transition into the clinical practice is still lagging. This delay could be attributed to the contradictory paradigms and the conflicting results that have been obtained from experimental models, as well as the presence of inconsistent reports regarding their safety. In this review, we summarize the potential mechanisms underlying the neuroprotective effects of medical gases and discuss possible candidates that could improve the outcomes of brain injury.
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Affiliation(s)
- Yue-Zhen Wang
- Department of Anesthesiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Ting-Ting Li
- Department of Anesthesiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Hong-Ling Cao
- Department of Anesthesiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Wan-Chao Yang
- Department of Anesthesiology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
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Wong C, Churilov L, Cowie D, Tan CO, Hu R, Tremewen D, Pearce B, Pillai P, Karalapillai D, Bellomo R, Weinberg L. Randomised controlled trial to investigate the relationship between mild hypercapnia and cerebral oxygen saturation in patients undergoing major surgery. BMJ Open 2020; 10:e029159. [PMID: 32066598 PMCID: PMC7045198 DOI: 10.1136/bmjopen-2019-029159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The effects of hypercapnia on regional cerebral oxygen saturation (rSO2) during surgery are unclear. We conducted a randomised controlled trial to investigate the relationship between mild hypercapnia and rSO2. We hypothesised that, compared with targeted normocapnia (TN), targeted mild hypercapnia (TMH) during major surgery would increase rSO2. DESIGN A prospective, randomised, controlled trial in adult participants undergoing elective major surgery. SETTING A single tertiary centre in Heidelberg, Victoria, Australia. PARTICIPANTS 40 participants were randomised to either a TMH or TN group (20 to each). INTERVENTIONS TMH (partial pressure of carbon dioxide in arterial blood, PaCO2, 45-55 mm Hg) or TN (PaCO2 35-40 mm Hg) was delivered via controlled ventilation throughout surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was the absolute difference between the two groups in percentage change in rSO2 from baseline to completion of surgery. Secondary endpoints included intraoperative pH, bicarbonate concentration, base excess, serum potassium concentration, incidence of postoperative delirium and length of stay (LOS) in hospital. RESULTS The absolute difference between the two groups in percentage change in rSO2 from the baseline to the completion of surgery was 19.0% higher in both hemispheres with TMH (p<0.001). On both sides, the percentage change in rSO2 was greater in the TMH group than the TN group throughout the duration of surgery. The difference between the groups became more noticeable over time. Furthermore, postoperative delirium was higher in the TN group (risk difference 0.3, 95% CI 0.1 to 0.5, p=0.02). LOS was similar between groups (5 days vs 5 days; p=0.99). CONCLUSION TMH was associated with a stable increase in rSO2 from the baseline, while TN was associated with a decrease in rSO2 in both hemispheres in patients undergoing major surgery. This resulted in a clear separation of percentage change in rSO2 from the baseline between TMH and TN over time. Our findings provide the rationale for larger studies on TMH during surgery. TRIAL REGISTRATION NUMBER The Australian New Zealand Clinical Trials Registry (ACTRN12616000320459).
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Affiliation(s)
- Clarence Wong
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- The Department of Medicine, Austin Health, The Univesity of Melbourne, Heidelberg, Victoria, Australia
| | - Dean Cowie
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - David Tremewen
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Param Pillai
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
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Yang WC, Wang Q, Chi LT, Wang YZ, Cao HL, Li WZ. Therapeutic hypercapnia reduces blood-brain barrier damage possibly via protein kinase Cε in rats with lateral fluid percussion injury. J Neuroinflammation 2019; 16:36. [PMID: 30760300 PMCID: PMC6375143 DOI: 10.1186/s12974-019-1427-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/01/2019] [Indexed: 11/17/2022] Open
Abstract
Background This study investigated whether therapeutic hypercapnia (TH) ameliorated blood–brain barrier (BBB) damage and improved the neurologic outcome in a rat model of lateral fluid percussion injury (FPI), and explored the possible underlying mechanism. Methods Rats underwent lateral FPI and received inhalation of 30%O2–70%N2 or 30%O2–N2 plus CO2 to maintain arterial blood CO2 tension (PaCO2) between 80 and 100 mmHg for 3 h. To further explore the possible mechanisms for the protective effects of TH, a PKC inhibitor staurosporine or PKCαβ inhibitor GÖ6976 was administered via intracerebral ventricular injection. Results TH significantly improved neurological function 24 h, 48 h, 7 d, and 14 d after FPI. The wet/dry ratio, computed tomography values, Evans blue content, and histological lesion volume were significantly reduced by TH. Moreover, numbers of survived neurons and the expression of tight junction proteins (ZO-1, occludin, and claudin-5) were significantly elevated after TH treatment at 48-h post-FPI. TH significantly increased the expression of protein kinase Cε (PKCε) at 48-h post-FPI, but did not significantly change the expression of PKCα and PKCβII. PKC inhibitor staurosporine (but not the selective PKCαβ inhibitor-GÖ6976) inhibited the protective effect of TH. Conclusions Therapeutic hypercapnia is a promising candidate that should be further evaluated for clinical treatment. It not only protects the traumatic penumbra from secondary injury and improves histological structure but also maintains the integrity of BBB and reduces neurologic deficits after trauma in a rat model of FPI.
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Affiliation(s)
- Wan-Chao Yang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qi Wang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lai-Ting Chi
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yue-Zhen Wang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong-Ling Cao
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wen-Zhi Li
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China. .,Anesthesiology Key Laboratory, Education Department, Harbin Medical University, No. 246 Xuefu Road, Harbin, 150086, China.
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Kasdorf E, Perlman JM. General Supportive Management of the Term Infant With Neonatal Encephalopathy Following Intrapartum Hypoxia-Ischemia. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00005-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Tolaymat Y, Doré S, Griffin HW, Shih S, Edwards ME, Weiss MD. Inhaled Gases for Neuroprotection of Neonates: A Review. Front Pediatr 2019; 7:558. [PMID: 32047729 PMCID: PMC6996209 DOI: 10.3389/fped.2019.00558] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022] Open
Abstract
Importance: Hypoxic-ischemic encephalopathy (HIE) is a significant cause of morbidity and mortality in neonates. The incidence of HIE is 1-8 per 1,000 live births in developed countries. Whole-body hypothermia reduces the risk of disability or death, but 7 infants needed to be treated to prevent death or major neurodevelopmental disability. Inhalational gases may be promising synergistic agents due to their rapid onset and easy titratability. Objective: To review current data on different inhaled gases with neuroprotective properties that may serve as adjunct therapies to hypothermia. Evidence review: Literature review was performed using the PubMed database, google scholar, and ClinicalTrials.Gov. Results focused on articles published from January 1, 2005, through December 31, 2017. Articles published earlier than 2005 were included when appropriate for historical perspective. Our review emphasized preclinical and clinical studies relevant to the use of inhaled agents for neuroprotection. Findings: Based on the relevance to our topic, 111 articles were selected pertaining to the incidence of HIE, pathophysiology of HIE, therapeutic hypothermia, and emerging therapies for hypoxic-ischemic encephalopathy in preclinical and clinical settings. Supplemental tables summarizes highly relevant 49 publications that were included in this review. The selected publications emphasize the emergence of promising inhaled gases that may improve neurologic survival and alleviate neurodevelopmental disability when combined with therapeutic hypothermia in the future. Conclusions: Many inhaled agents have neuroprotective properties and could serve as an adjunct therapy to whole-body hypothermia. Inhaled agents are ideal due to their easy administration, titrability, and rapid onset and offset.
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Affiliation(s)
- Youness Tolaymat
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Sylvain Doré
- Departments of Neurology, Psychiatry, Pharmaceuticals and Neuroscience, University of Florida, Gainesville, FL, United States
| | - Hudson W Griffin
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Susana Shih
- Department of Anesthesiology, University of Florida, Gainesville, FL, United States
| | - Mary E Edwards
- Health Science Center Libraries, University of Florida, Gainesville, FL, United States
| | - Michael D Weiss
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
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Lopez Laporte MA, Wang H, Sanon PN, Barbosa Vargas S, Maluorni J, Rampakakis E, Wintermark P. Association between hypocapnia and ventilation during the first days of life and brain injury in asphyxiated newborns treated with hypothermia. J Matern Fetal Neonatal Med 2017; 32:1312-1320. [DOI: 10.1080/14767058.2017.1404980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Maria Agustina Lopez Laporte
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children’s Hospital, McGill University, Montreal, Canada
| | - Hui Wang
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children’s Hospital, McGill University, Montreal, Canada
| | - Priscille-Nice Sanon
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children’s Hospital, McGill University, Montreal, Canada
| | - Stephanie Barbosa Vargas
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children’s Hospital, McGill University, Montreal, Canada
| | - Julie Maluorni
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children’s Hospital, McGill University, Montreal, Canada
| | | | - Pia Wintermark
- Department of Pediatrics, Division of Newborn Medicine, Montreal Children’s Hospital, McGill University, Montreal, Canada
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Almenrader N, Colucci P, De Castro V, Valeri D, Palmery M, Trezza V, Campolongo P. Effects of sevoflurane and clonidine on acid base status and long-term emotional and cognitive outcomes in spontaneously breathing rat pups. PLoS One 2017; 12:e0173969. [PMID: 28319126 PMCID: PMC5358762 DOI: 10.1371/journal.pone.0173969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 03/01/2017] [Indexed: 12/20/2022] Open
Abstract
Background Numerous experiments in rodents suggest a causative link between exposure to general anaesthetics during brain growth spurt and poor long-lasting neurological outcomes. Many of these studies have been questioned with regard of their translational value, mainly because of extremely long anaesthesia exposure. Therefore, the aim of the present study was to assess the impact of a short sevoflurane anaesthesia, alone or combined with clonidine treatment, on respiratory function in spontaneously breathing rat pups and overall effects on long-lasting emotional and cognitive functions. Methods At postnatal day (PND) 7, male Sprague Dawley rat pups were randomized into four groups and exposed to sevoflurane for one hour, to a single dose of intraperitoneal clonidine or to a combination of both and compared to a control group. Blood gas analysis was performed at the end of sevoflurane anaesthesia and after 60 minutes from clonidine or saline injection. Emotional and cognitive outcomes were evaluated in different group of animals at infancy (PND12), adolescence (PND 30–40) and adulthood (PND 70–90). Results Rat pups exposed to either sevoflurane or to a combination of sevoflurane and clonidine developed severe hypercapnic acidosis, but maintained normal arterial oxygenation. Emotional and cognitive outcomes were not found altered in any of the behavioural task used either at infancy, adolescence or adulthood. Conclusions Sixty minutes of sevoflurane anaesthesia in newborn rats, either alone or combined with clonidine, caused severe hypercapnic acidosis in spontaneously breathing rat pups, but was devoid of long-term behavioural dysfunctions in the present setting.
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Affiliation(s)
- Nicole Almenrader
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
- Department of Anaesthesia and Intensive Care, Policlinico Umberto I, Rome, Italy
| | - Paola Colucci
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Valentina De Castro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Daniela Valeri
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Maura Palmery
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Viviana Trezza
- Department of Science, Section of Biomedical Sciences and Technologies, University “Roma Tre”, Rome, Italy
| | - Patrizia Campolongo
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
- * E-mail:
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Relationship between PCO2 and unfavorable outcome in infants with moderate-to-severe hypoxic ischemic encephalopathy. Pediatr Res 2016; 80:204-8. [PMID: 27049290 DOI: 10.1038/pr.2016.62] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/26/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Abnormal PCO2 is common in infants with hypoxic ischemic encephalopathy (HIE). The objective was to determine whether hypocapnia was independently associated with unfavorable outcome (death or severe neurodevelopmental disability at 18 mo) in infants with moderate-to-severe HIE. METHODS This was a post hoc analysis of the CoolCap Study in which infants were randomized to head cooling or standard care. Blood gases were measured at prespecified times after randomization. PCO2 and follow-up data were available for 196 of 234 infants. Analyses were performed to investigate the relationship between hypocapnia in the first 72 h after randomization and unfavorable outcome. RESULTS After adjusting for pH, amplitude-integrated electroencephalogram background and seizures, birth weight, Apgar score at 5 min, cooling status, and Sarnat stage, PCO2 was inversely associated with unfavorable outcome (P < 0.001). The probability of unfavorable outcome was 0.20 ± 0.1 (point estimate ± SE), 0.53 ± 0.23 and 0.89 ± 0.16 for a PCO2 of 40, 30, and 20 mm Hg respectively and was greater in infants with severe HIE than with moderate HIE. CONCLUSIONS Hypocapnia in infants with moderate-to-severe HIE was independently associated with unfavorable outcome. Future studies of controlled normocapnia will be important.
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Yang W, Zhang X, Wang N, Tan J, Fang X, Wang Q, Tao T, Li W. Effects of Acute Systemic Hypoxia and Hypercapnia on Brain Damage in a Rat Model of Hypoxia-Ischemia. PLoS One 2016; 11:e0167359. [PMID: 27907083 PMCID: PMC5131999 DOI: 10.1371/journal.pone.0167359] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/12/2016] [Indexed: 12/18/2022] Open
Abstract
Therapeutic hypercapnia has the potential for neuroprotection after global cerebral ischemia. Here we further investigated the effects of different degrees of acute systemic hypoxia in combination with hypercapnia on brain damage in a rat model of hypoxia and ischemia. Adult wistar rats underwent unilateral common carotid artery (CCA) ligation for 60 min followed by ventilation with normoxic or systemic hypoxic gas containing 11%O2,13%O2,15%O2 and 18%O2 (targeted to PaO2 30-39 mmHg, 40-49 mmHg, 50-59 mmHg, and 60-69 mmHg, respectively) or systemic hypoxic gas containing 8% carbon dioxide (targeted to PaCO2 60-80 mmHg) for 180 min. The mean artery pressure (MAP), blood gas, and cerebral blood flow (CBF) were evaluated. The cortical vascular permeability and brain edema were examined. The ipsilateral cortex damage and the percentage of hippocampal apoptotic neurons were evaluated by Nissl staining and terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate-biotin nick end labeling (TUNEL) assay as well as flow cytometry, respectively. Immunofluorescence and western blotting were performed to determine aquaporin-4 (AQP4) expression. In rats treated with severe hypoxia (PaO2 < 50 mmHg), hypercapnia augmented the decline of MAP with cortical CBF and damaged blood-brain barrier permeability (p < 0.05). In contrast, in rats treated with mild to moderate hypoxia (PaO2 > 50 mmHg), hypercapnia protected against these pathophysiological changes. Moreover, hypercapnia treatment significantly reduced brain damage in the ischemic ipsilateral cortex and decreased the percentage of apoptotic neurons in the hippocampus after the CCA ligated rats were exposed to mild or moderate hypoxemia (PaO2 > 50 mmHg); especially under mild hypoxemia (PaO2 > 60 mmHg), hypercapnia significantly attenuated the expression of AQP4 protein with brain edema (p < 0.05). Hypercapnia exerts beneficial effects under mild to moderate hypoxemia and augments detrimental effects under severe hypoxemia on brain damage in a rat model of hypoxia-ischemia.
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Affiliation(s)
- Wanchao Yang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Xuezhong Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Nan Wang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Jing Tan
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Xianhai Fang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Qi Wang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Tao Tao
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
| | - Wenzhi Li
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University P. R. China; and Anesthesiology Key Laboratory, Education Department, Harbin Medical University, Heilongjiang Province, P. R. China
- * E-mail:
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Roberts BW, Karagiannis P, Coletta M, Kilgannon JH, Chansky ME, Trzeciak S. Effects of PaCO2 derangements on clinical outcomes after cerebral injury: A systematic review. Resuscitation 2015; 91:32-41. [PMID: 25828950 DOI: 10.1016/j.resuscitation.2015.03.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/04/2015] [Accepted: 03/09/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Partial pressure of arterial carbon dioxide (PaCO2) is a major regulator of cerebral blood flow (CBF). Derangements in PaCO2 have been thought to worsen clinical outcomes after many forms of cerebral injury by altering CBF. Our aim was to systematically analyze the biomedical literature to determine the effects of PaCO2 derangements on clinical outcomes after cerebral injury. METHODS We performed a search of Cochrane Library, PUBMED, CINHAL, conference proceedings, and other sources using a comprehensive strategy. Study inclusion criteria were (1) human subjects; (2) cerebral injury; (3) mechanical ventilation post-injury; (4) measurement of PaCO2; and (5) comparison of a clinical outcome measure (e.g. mortality) between different PaCO2 exposures. We performed a qualitative analysis to collate and summarize effects of PaCO2 derangements according to the recommended methodology from the Cochrane Handbook. RESULTS Seventeen studies involving different etiologies of cerebral injury (six traumatic brain injury, six post-cardiac arrest syndrome, two cerebral vascular accident, three neonatal ischemic encephalopathy) met all inclusion and no exclusion criteria. Three randomized control trials were identified and only one was considered a high quality study as per the Cochrane criteria for assessing risk of bias. In 13/17 (76%) studies examining hypocapnia, and 7/10 (70%) studies examining hypercapnia, the exposed group (hypercapnia or hypocapnia) was associated with poor clinical outcome. CONCLUSION The majority of studies in this report found exposure to hypocapnia and hypercapnia after cerebral injury to be associated with poor clinical outcome. However, the optimal PaCO2 range associated with good clinical outcome remains unclear.
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Affiliation(s)
- Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Paul Karagiannis
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Michael Coletta
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Michael E Chansky
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Stephen Trzeciak
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA; Department of Medicine, Division of Critical Care Medicine (ST), Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
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Hypercapnia and Neuroprotection. Crit Care Med 2014; 42:1561-2. [DOI: 10.1097/ccm.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Deng J, Lei C, Chen Y, Fang Z, Yang Q, Zhang H, Cai M, Shi L, Dong H, Xiong L. Neuroprotective gases – Fantasy or reality for clinical use? Prog Neurobiol 2014; 115:210-45. [DOI: 10.1016/j.pneurobio.2014.01.001] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/03/2014] [Accepted: 01/03/2014] [Indexed: 12/17/2022]
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Lee BK, Jeung KW, Lee HY, Lee SJ, Jung YH, Lee WK, Heo T, Min YI. Association between mean arterial blood gas tension and outcome in cardiac arrest patients treated with therapeutic hypothermia. Am J Emerg Med 2014; 32:55-60. [DOI: 10.1016/j.ajem.2013.09.044] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/28/2013] [Accepted: 09/28/2013] [Indexed: 11/16/2022] Open
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Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest. Resuscitation 2013; 84:927-34. [DOI: 10.1016/j.resuscitation.2013.02.014] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 01/31/2013] [Accepted: 02/21/2013] [Indexed: 11/23/2022]
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Tachibana K, Hashimoto T, Takita K, Ito R, Kato R, Morimoto Y. Neonatal exposure to high concentration of carbon dioxide produces persistent learning deficits with impaired hippocampal synaptic plasticity. Brain Res 2013; 1507:83-90. [PMID: 23466457 DOI: 10.1016/j.brainres.2013.02.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 02/09/2013] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
Abstract
Although respiratory complications with blood gas abnormalities contribute significantly to neurodevelopment in the immature brain, little is known about the mechanisms via which blood gas abnormalities, such as hypoxic hypercapnia, impair neurocognitive outcomes. To investigate the possible long-term consequences of neonatal exposure to hypoxic hypercapnia regarding learning ability, we investigated the effect of neonatal hypoxic hypercapnia on later functions in the hippocampus, which is a structure that has been implicated in many learning and memory processes. Neonatal rat pups (postnatal day 7; P7) were exposed to a high concentration of carbon dioxide (CO2; 13%) for 2 or 4h. Exposure to CO2 in P7 rat pups caused blood gas abnormalities, including hypercapnia, hypoxia, and acidosis, and disrupted later learning acquisition, as assessed in 10-week-old adult rats subjected to a Morris water maze test. Induction of long-term potentiation (LTP) in the synapses of the hippocampal CA1 area was also impaired, whereas the paired-pulse responses of population spikes exhibited a significant increase, in CO2-exposed rats, suggesting decreased recurrent inhibition in the hippocampus. Such long-lasting modifications in hippocampal synaptic plasticity may contribute to the learning impairments associated with perinatal hypoxic hypercapnia and acidosis.
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Affiliation(s)
- Kaori Tachibana
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan.
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Go SL, Singh JM. Pro/con debate: should PaCO2 be tightly controlled in all patients with acute brain injuries? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:202. [PMID: 23360555 PMCID: PMC4056635 DOI: 10.1186/cc11389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
You are the attending intensivist in a neurointensive care unit caring for a woman five days post-rupture of a cerebral aneurysm (World Federation of Neurological Surgeons Grade 4 and Fisher Grade 3). She is intubated for airway protection and mild hypoxemia related to an aspiration event at the time of aneurysm rupture, but is breathing spontaneously on the ventilator. Your patient is spontaneously hyperventilating with high tidal volumes despite minimal support and has developed significant hypocapnia. She has not yet developed the acute respiratory distress syndrome. You debate whether to tightly control her partial pressure of arterial carbon dioxide, weighing the known risks of acute hypocapnia in other forms of brain injury against the potential loss of clinical neuromonitoring associated with deep sedation and neuromuscular blockade in this patient who is at high risk of delayed ischemia from vasospasm. You are also aware of the potential implications of tidal volume control if this patient were to develop the acute respiratory distress syndrome and the effect of permissive hypercapnia on her intracranial pressure. In this paper we provide a detailed and balanced examination of the issues pertaining to this clinical scenario, including suggestions for clinical management of ventilation, sedation and neuromonitoring. Until more definitive clinical trial evidence is available to guide practice, clinicians are forced to carefully weigh the potential benefits of tight carbon dioxide control against the potential risks in each individual patient based on the clinical issues at hand.
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Tsuji T, Aoshiba K, Itoh M, Nakamura H, Yamaguchi K. Hypercapnia accelerates wound healing in endothelial cell monolayers exposed to hypoxia. Open Respir Med J 2013; 7:6-12. [PMID: 23524473 PMCID: PMC3601342 DOI: 10.2174/1874306401307010006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/01/2013] [Accepted: 02/03/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION While tissue hypoxia is known to play a critical role in the process of vascular injury and repair, the effect of hypercapnia on this process remains uncertain. We investigated whether hypercapnia might influence endothelial cell wound healing under the influence of hypoxia. MATERIALS AND METHODOLOGY Monolayers of human umbilical venous endothelial cells (HUVECs) were scratch-wounded and incubated under different levels of O2, CO2, and pH in the environment. RESULTS Inhibition of wound healing was observed in the HUVEC monolayers under the hypoxic condition as compared to the normoxic condition. Both hypercapnic acidosis and buffered hypercapnia, but not normocapnic acidosis improved the rate of wound healing under the influence of hypoxia. The beneficial effect of hypercapnia was associated with stimulation of cell proliferation, without effects on cell adhesion, migration or apoptosis. On the other hand, the stimulatory effect of hypercapnia on wound healing and cell proliferation was not noted under normoxic conditions. CONCLUSION These results suggest that hypercapnia, rather than acidosis per se, accelerated the wound healing in HUVEC monolayers cultured under hypoxic conditions. The effect of hypercapnia on wound healing was due, at least in part, to the stimulation of cell proliferation by hypercapnia.
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Affiliation(s)
- Takao Tsuji
- Department of Respiratory Medicine, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuou, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Kazutetsu Aoshiba
- Department of Respiratory Medicine, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuou, Ami, Inashiki, Ibaraki 300-0395, Japan
- Address correspondence to this author at the Department of Respiratory Medicine, Tokyo Medical University Ibaraki Medical Center3-20-1, Chuou, Ami, Inashiki, Ibaraki 300-0395, Japan; Tel: 81-29-887-1161;
Fax 81-29-888-3463; E-mail:
| | - Masayuki Itoh
- Department of Respiratory Medicine, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuou, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Hiroyuki Nakamura
- Department of Respiratory Medicine, Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuou, Ami, Inashiki, Ibaraki 300-0395, Japan
| | - Kazuhiro Yamaguchi
- Comprehensive and Internal Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10 nishi-ogu, Arakawa-ku, Tokyo 116-8567, Japan
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Abstract
The interruption of placental blood flow induces circulatory responses to maintain cerebral, cardiac, and adrenal blood flow with reduced renal, hepatic, intestinal, and skin blood flow. If placental compromise is prolonged and/or severe, total circulatory failure is likely with cerebral hypoperfusion and resultant hypoxic ischemic cerebral injury with collateral renal, cardiac, and hepatic injury. Management strategies should be targeted at restoring cerebral perfusion and oxygen delivery and minimizing the extent of secondary injury. Specifically, the focus should include the judicious use of supplemental oxygen, avoidance of hypoglycemia and elevated temperature in the delivery room, and the early administration of therapeutic hypothermia to high-risk infants.
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Affiliation(s)
- Jeffrey M Perlman
- Division of Newborn Medicine, Department of Pediatrics, Weill Cornell Medical College, 525 East 68th Street, Suite N-506, New York, NY 10065, USA.
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Fung SJ, Xi M, Zhang J, Sampogna S, Chase MH. Apnea produces excitotoxic hippocampal synapses and neuronal apoptosis. Exp Neurol 2012; 238:107-13. [PMID: 22921462 DOI: 10.1016/j.expneurol.2012.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 07/27/2012] [Accepted: 08/03/2012] [Indexed: 12/20/2022]
Abstract
Obstructive sleep apnea (OSA) results in the degeneration of neurons in the hippocampus that eventuates in neurocognitive deficits. We were therefore interested in determining the effects of apnea on monosynaptic excitatory processes in a hippocampal pathway (cornu ammonis 3-cornu ammonis 1, CA3-CA1) that has been shown to mediate the processing of cognitive information. In addition, to substantiate an anatomical basis for the cognitive dysfunction that occurs in OSA patients, we examined the effects of apnea with respect to neurodegenerative changes (apoptosis) in the same hippocampal pathway. In order to determine the effects of apnea, an automated system for the generation and analysis of single and recurrent periods of apnea was developed. Utilizing this system, the field excitatory postsynaptic potential (fEPSP) generated by pyramidal neurons in the CA1 region of the hippocampus was monitored in α-chloralose anesthetized rats following stimulation of glutamatergic afferents in the CA3 region. A stimulus-response (input-output) curve for CA3-CA1 synaptic activity was determined. In addition, a paired-pulse paradigm was employed to evaluate, electrophysiologically, the presynaptic release of glutamate. Changes in the synaptic efficacy were assessed following single episodes of apnea induced by ventilatory arrest (60 to 80 s duration, mean=72 s; mean oxygen desaturation was 53% of normoxia level). Apnea resulted in a significant potentiation of the amplitude (mean=126%) and slope (mean=117%) of the baseline CA1 fEPSP. This increase in the fEPSP was accompanied by a significant decrease in the amplitude (71%) and slope (81%) of normalized paired-pulse facilitation (PPF) ratios. Since the potentiation of the fEPSP is inversely proportional to changes in PPF ratio, the potentiated fEPSP accompanied by the reduced PPF reveals that apnea produces an abnormal increase in the preterminal release of glutamate that results in the over-activation (and calcium overloading) of hippocampal CA1 neurons. Thus, we conclude that individual episodes of apnea result in the development of excitotoxic processes in the hippocampal CA3-CA1 pathway that is critically involved in the processing of cognitive information. Morphologically, the deleterious effect of recurrent apnea was substantiated by the finding of apoptosis in CA1 neurons of apneic (but not normoxic) animals.
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Affiliation(s)
- Simon J Fung
- VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA.
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Curley G, Laffey J. Hypocapnia induced cerebral ischaemia during therapeutic hypothermia—Potential for harm? Resuscitation 2011; 82:1122-3. [DOI: 10.1016/j.resuscitation.2011.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Analysis of the changes in the oxidation of brain tissue cytochrome-c-oxidase in traumatic brain injury patients during hypercapnoea: a broadband NIRS study. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2011; 701:9-14. [PMID: 21445763 PMCID: PMC4038017 DOI: 10.1007/978-1-4419-7756-4_2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Using broadband near-infrared spectroscopy (NIRS) and cerebral microdialysis (MD),we investigated cerebral cellular metabolism and mitochondrial redox states, following hypercapnoea in 6 patients with traumatic brain injury (TBI). In all patients hypercapnoea increased intracranial pressure and cerebral blood flow velocity measured with transcranial Doppler. Despite the likely increase in cerebral oxygen delivery, we did not see an increase in the oxidation status of cytochrome-c-oxidase [oxCCO] in every patient. Analysis of the NIRS data demonstrated two patterns of the changes; Group A (n = 4) showed an increase in [oxCCO] of 0.34(± 0.34)µM and Group B (n = 2) a decrease of 0.40(± 0.41)µM. Although no obvious association was seen between the Δ[oxCCO] and the MD, measured changes in lactate and pyruvate concentrations. Further work using model informed data interpretation may be helpful in understanding the multimodal signals acquired in this heterogeneous patient group.
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Thews O, Nowak M, Sauvant C, Gekle M. Hypoxia-induced extracellular acidosis increases p-glycoprotein activity and chemoresistance in tumors in vivo via p38 signaling pathway. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2011; 701:115-22. [PMID: 21445777 DOI: 10.1007/978-1-4419-7756-4_16] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Due to inadequate perfusion, tumors develop hypoxia and extracellular acidosis. In vitro, this acidic environment (pH=6.6) has a strong impact on the activity of the p-glycoprotein (pGP) drug transporter responsible for multidrug resistance. This effect is most probably mediated via p38 and/or ERK1/2 signalling pathways. The aim of the study was to analyze whether these findings also play a role for chemosensitivity in solid growing tumors in vivo. Therefore, experimental R3327-AT1 tumors of the rat were exposed to an acidifying treatment leading to forced glycolysis. The intratumoral pO(2)1 was determined polarographically and the extracellular pH was measured with needle electrodes. In addition the cytotoxicity of daunorubicin chemotherapy was assessed. Tumor oxygenation was markedly worsened by the acidosis treatment leading to a mean tumor pO(2) of 1 mmHg. This hypoxia resulted in a pronounced acidification of the tumor tissue from pH 7.04 down to 6.65. Extracellular acidosis in vivo decreased caspase 3-activity after daunorubicin treatment by 30%indicating a reduced chemosensitivity. Inhibition of the p38 signalling pathway restored the reduced chemosensitivity at least partially. However, in contrast to the in vitro findings inhibition of ERK1/2 had practically no impact in vivo.
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Affiliation(s)
- Oliver Thews
- Institute of Physiology and Pathophysiology, University of Mainz, 55099 Mainz, Germany.
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Bench-to-bedside review: hypercapnic acidosis in lung injury--from 'permissive' to 'therapeutic'. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:237. [PMID: 21067531 PMCID: PMC3220022 DOI: 10.1186/cc9238] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Modern ventilation strategies for patients with acute lung injury and acute respiratory distress syndrome frequently result in hypercapnic acidosis (HCA), which is regarded as an acceptable side effect ('permissive hypercapnia'). Multiple experimental studies have demonstrated advantageous effects of HCA in several lung injury models. To date, however, human trials studying the effect of carbon dioxide per se on outcome in patients with lung injury have not been performed. While significant concerns regarding HCA remain, in particular the possible unfavorable effects on bacterial killing and the inhibition of pulmonary epithelial wound repair, the potential for HCA in attenuating lung injury is promising. The underlying mechanisms by which HCA exerts its protective effects are complex, but dampening of the inflammatory response seems to play a pivotal role. After briefly summarizing the physiological effects of HCA, a critical analysis of the available evidence on the potential beneficial effects of therapeutic HCA from in vitro, ex vivo and in vivo lung injury models and from human studies will be reviewed. In addition, the potential concerns in the clinical setting will be outlined.
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Establishing gas exchange and improving oxygenation in the delivery room management of the lung. Adv Neonatal Care 2010; 10:256-60. [PMID: 20838076 DOI: 10.1097/anc.0b013e3181f0836d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
One of the components of promoting good outcomes in high-risk neonates is supporting normal gas exchange while avoiding lung injury. Respiratory care in the first hour following birth plays an important role in stabilizing the infant with respiratory problems. The goal of this article is to review the causes of lung injury that can occur in the first hour and that could be prevented with careful respiratory support.
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Durduran T, Zhou C, Buckley EM, Kim MN, Yu G, Choe R, Gaynor JW, Spray TL, Durning SM, Mason SE, Montenegro LM, Nicolson SC, Zimmerman RA, Putt ME, Wang J, Greenberg JH, Detre JA, Yodh AG, Licht DJ. Optical measurement of cerebral hemodynamics and oxygen metabolism in neonates with congenital heart defects. JOURNAL OF BIOMEDICAL OPTICS 2010; 15:037004. [PMID: 20615033 PMCID: PMC2887915 DOI: 10.1117/1.3425884] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Revised: 03/02/2010] [Accepted: 03/12/2010] [Indexed: 05/18/2023]
Abstract
We employ a hybrid diffuse correlation spectroscopy (DCS) and near-infrared spectroscopy (NIRS) monitor for neonates with congenital heart disease (n=33). The NIRS-DCS device measured changes during hypercapnia of oxyhemoglobin, deoxyhemoglobin, and total hemoglobin concentrations; cerebral blood flow (rCBF(DCS)); and oxygen metabolism (rCMRO(2)). Concurrent measurements with arterial spin-labeled magnetic resonance imaging (rCBF(ASL-MRI), n=12) cross-validate rCBF(DCS) against rCBF(ASL-MRI), showing good agreement (R=0.7, p=0.01). The study demonstrates use of NIRS-DCS on a critically ill neonatal population, and the results indicate that the optical technology is a promising clinical method for monitoring this population.
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Affiliation(s)
- Turgut Durduran
- ICFO-Institut de Ciencies Fotoniques, Av Canal Olimpic s/n, Castelldefels 08860, Spain.
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Yager JY, Armstrong EA, Black AM. Treatment of the term newborn with brain injury: simplicity as the mother of invention. Pediatr Neurol 2009; 40:237-43. [PMID: 19218037 DOI: 10.1016/j.pediatrneurol.2008.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 11/03/2008] [Indexed: 11/28/2022]
Abstract
Neonatal brain injury remains a common cause of developmental disability, despite tremendously enhanced obstetrical and neonatal care. The timing of brain injury occurs throughout gestation, labor, and delivery, providing an evolving form of brain injury and a moving target for therapeutic intervention. Nonetheless, markedly improved methods are available to identify those infants injured at birth, via clinical presentation with neonatal encephalopathy and neuroimaging techniques. Postischemic hypothermia has been shown to be of tremendous clinical promise in several completed and ongoing trials. As part of this approach to the treatment of the newborn, other parameters of physiologic homeostasis can and should be attended to, with strong animal and clinical evidence that their correction will have dramatic influence on the outcome of the newborn infant. This review addresses aspects of newborn care to which we can direct our attention currently, and which should result in a safe and efficacious improvement in the prognosis of the newborn with neonatal encephalopathy.
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Affiliation(s)
- Jerome Y Yager
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
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Hassett P, Contreras M, Laffey JG. Hypercapnia: Permissive, Therapeutic, or Not at All? Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Key Questions in Ventilator Management of the Burn-Injured Patient (First of Two Parts). J Burn Care Res 2009; 30:128-38. [DOI: 10.1097/bcr.0b013e318191fe44] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
UNLABELLED 'Permissive hypercapnia' is a familiar term in neonatal intensive care, given the widespread adoption of low-tidal-volume ventilation strategies applied with the goal of decreasing respiratory morbidity. Recent evidence suggesting that hypercapnic acidosis may itself have protective effects on the lung and other organs has led to the coining of a new phrase, 'therapeutic hypercapnia', which also encompasses the use of supplemental inspired CO(2). CONCLUSION Experimental evidence suggests that mild-moderate hypercapnia can improve tissue oxygenation and perfusion, which may ameliorate injury to the immature lung and brain. However, hypercapnia may also be associated with adverse outcomes, and the range of PaCO(2) levels that are both safe and effective for specific subsets of neonates has yet to be determined.
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Affiliation(s)
- Robert P Jankov
- Department of Paediatric, University of Toronto, Toronto, Ontario Canada.
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Skoumalová A, Herget J, Wilhelm J. Hypercapnia protects erythrocytes against free radical damage induced by hypoxia in exposed rats. Cell Biochem Funct 2008; 26:801-7. [DOI: 10.1002/cbf.1509] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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The potential role of carbon dioxide in the neuroimmunoendocrine changes following cerebral ischemia. Life Sci 2008; 83:381-7. [DOI: 10.1016/j.lfs.2008.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 06/29/2008] [Accepted: 07/17/2008] [Indexed: 12/18/2022]
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Murkin JM. Cerebral autoregulation: the role of CO2 in metabolic homeostasis. Semin Cardiothorac Vasc Anesth 2008; 11:269-73. [PMID: 18270191 DOI: 10.1177/1089253207311159] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this review the role of PaCO2 in regulating cerebral blood flow and flow/metabolism coupling, as well as its impact on intracellular metabolic processes are discussed. Starting with a discussion of alpha-stat versus pH-stat ventilatory management, the apparently contradictory finding of exacerbation of ischemic injury by extracellular acidosis in some experimental models versus others in which neuroprotection is evidenced is discussed and contrasted with the conclusion that the relatively small degree of change in pH associated with clinical changes in PaCO2 is unlikely to directly impact ischemia/reperfusion processes. However, examples of susceptible patients in whom relatively small changes in PaCO2 can produce adverse effects on cerebral perfusion are also illustrated re-emphasizing the necessity for individualization rather than generalization of care.
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Affiliation(s)
- John M Murkin
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada.
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Liske MR, Aschner JL. Counterpoint: Hypoxia is not the Optimal Means of Reducing Pulmonary Blood Flow in the Preoperative Single Ventricle Heart. J Appl Physiol (1985) 2008; 104:1836-8; discussion 1838-9. [DOI: 10.1152/japplphysiol.00154.2008a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Rebuttal by Aschner and Liske. J Appl Physiol (1985) 2008. [DOI: 10.1152/japplphysiol.00154.2008c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Brown DA, Maclellan WR, Wu BM, Beygui RE. Analysis of pH gradients resulting from mass transport limitations in engineered heart tissue. Ann Biomed Eng 2007; 35:1885-97. [PMID: 17680364 DOI: 10.1007/s10439-007-9360-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Accepted: 07/17/2007] [Indexed: 10/23/2022]
Abstract
Transport limitations of critical nutrients are a major obstacle in the construction of engineered heart tissues (EHTs), and the importance of oxygen in this regard is well-documented throughout the literature. An indirect effect of cellular hypoxia is the shunt to the less-efficient glycolytic metabolism, which is accompanied by a reduction in extracellular pH. Image analysis of phenol red coloration in an experimental model of EHTs demonstrated pH gradients towards the center of the construct, which were dependent on experimental variables. Based on these observations, a four-species, 2-D diffusion-reaction mathematical model was developed to predict pH in a radial-diffusion model. The mathematical model predicted lethal values of pH (<6.5) in EHTs comprised of a nominal cell density of 10(6) cells/cm(3). pH predictions were moderately dependent on O(2) concentration, and strongly dependent on cell density, CO(2) concentration, and diffusion path length. It can be concluded from this study that hypoxia-induced acidosis is an important element in the mass transport problem, and future experiments measuring pH with more sensitive methods is expected to further elucidate the extent of this effect.
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Affiliation(s)
- David A Brown
- Department of Bioengineering, University of California, Los Angeles, 7523 Boelter Hall, 420 Westwood Plaza, Los Angeles, CA 90095, USA.
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Statler PA, McPherson RJ, Bauer LA, Kellert BA, Juul SE. Pharmacokinetics of high-dose recombinant erythropoietin in plasma and brain of neonatal rats. Pediatr Res 2007; 61:671-5. [PMID: 17426655 DOI: 10.1203/pdr.0b013e31805341dc] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recombinant human erythropoietin (rEpo) is neuroprotective in neonatal models of brain injury. Pharmacokinetic data regarding the penetration of circulating rEpo into brain tissue is needed to optimize neuroprotective strategies. We sought to determine the pharmacokinetics of rEpo given intraperitoneally or subcutaneously in plasma and brain. We hypothesized that 1) exogenous rEpo would penetrate the blood-brain barrier (BBB), 2) brain and plasma Epo would correlate, and 3) brain injury would enhance rEpo penetration. Two hundred and eighty-four 7-d-old control, sham, or brain-injured rats were treated with i.p. or s.c. rEpo (0, 250, 2500, or 5000 U/kg) and killed at scheduled intervals. Plasma and brain tissue were collected. Epo concentrations were measured by ELISA. Intraperitoneal injection yielded a faster and greater peak concentration of plasma rEpo (Tmax 3 h, Cmax 10,016 +/- 685 mU/mL) than s.c. injection (Tmax 9 h, Cmax 6224 +/- 753 mU/mL). Endogenous brain Epo was below detection even after hypoxia exposure. Systemic rEpo crossed the BBB in a dose-dependent manner, peaked in brain at 10 h, and was increased after brain injury. We conclude that high-dose rEpo is detectable in brain for >20 h after a single systemic injection. These pharmacokinetic data are valuable for planning of rEpo neuroprotection experiments.
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Affiliation(s)
- Pamela A Statler
- Department of Pediatrics, University of Washington, Seattle, Washington 98195, USA
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Logan JW, Cotten CM, Goldberg RN, Clark RH. Mechanical ventilation strategies in the management of congenital diaphragmatic hernia. Semin Pediatr Surg 2007; 16:115-25. [PMID: 17462564 DOI: 10.1053/j.sempedsurg.2007.01.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Most infants with congenital diaphragmatic hernia (CDH) require respiratory support. The goal of this report is to present an overview of mechanical ventilation strategies in the management of infants with CDH. The anatomic and physiologic limitations in the lungs of infants with diaphragmatic hernia make decisions on the best strategy and use of mechanical ventilation challenging. We will briefly review lung development in infants with CDH, identifying factors that provide a basis for lung protection strategies. Background on the use of specific mechanical ventilation modes and the rationale for each are provided. Finally, we review mechanical ventilation practices described in published case series of successful CDH management, with a brief review of additional treatments, including inhaled nitric oxide and extracorporeal membrane oxygenation. Although details of a single specific best strategy for mechanical ventilation for CDH infants cannot be identified from current literature, a lung protection ventilation approach, regardless of the device used, appears to reduce mortality risk.
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Affiliation(s)
- J Wells Logan
- Division of Neonatology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina 27710, USA
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Lasso Pirot A, Fritz KI, Ashraf QM, Mishra OP, Delivoria-Papadopoulos M. Effects of severe hypocapnia on expression of bax and bcl-2 proteins, DNA fragmentation, and membrane peroxidation products in cerebral cortical mitochondria of newborn piglets. Neonatology 2007; 91:20-7. [PMID: 17344648 DOI: 10.1159/000096967] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Accepted: 02/10/2006] [Indexed: 01/12/2023]
Abstract
BACKGROUND Hypocapnia occurs in the newborn infant inadvertently or as a therapeutic modality and may result in neuronal and mitochondrial alterations in the newborn brain. Since mitochondria regulate apoptosis, these alterations may initiate a cascade of reactions that lead to apoptotic cell death. OBJECTIVES This study tests the hypothesis that hypocapnia results in increased expression of the pro-apoptotic protein Bax, fragmentation of DNA and membrane lipid peroxidation in cerebral cortical mitochondria (mt) of newborn piglets. METHODS Studies were performed in three groups of anesthetized normoxic newborn piglets: hypocapnic (H, n = 5), ventilated at a PaCO(2) of 11-15 mm Hg; normocapnic (N, n = 5), ventilated at a PaCO(2) of 40 mm Hg; and corrected normocapnic (CN, n = 4), ventilated as H with CO(2) added to maintain normocapnia. Tissue ATP and phosphocreatine levels were determined. Mitochondrial membrane proteins were separated, transblotted and probed with antibodies to Bax and Bcl-2. Bands were detected by enhanced chemiluminescence and analyzed by imaging densitometry. mtDNA was isolated. Cell and mitochondrial membrane lipid peroxidation products were measured spectrofluorometrically. RESULTS ATP and PCr concentrations were similar in the 3 groups. The ratio of Bax/Bcl-2 increased significantly in H compared to N and CN. mtDNA fragmentation was also significantly greater in H compared to N or CN. Membrane lipid peroxidation was higher in H than in N or CN; and in CN compared to N. CONCLUSIONS The data demonstrate that severe hypocapnia results in increased Bax expression, DNA fragmentation, and membrane lipid peroxidation in mitochondria of cerebral cortical neurons of newborn piglets, and may result in apoptotic cell death.
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Affiliation(s)
- Anayansi Lasso Pirot
- Division of Pulmonology, Department of Pediatrics, University of Maryland, Baltimore, MD 21201 , USA.
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Xie Z, Moir RD, Romano DM, Tesco G, Kovacs DM, Tanzi RE. Hypocapnia induces caspase-3 activation and increases Abeta production. NEURODEGENER DIS 2006; 1:29-37. [PMID: 16908971 DOI: 10.1159/000076667] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2003] [Accepted: 09/29/2003] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND At least half of all cases of early onset (<60) familial Alzheimer's disease (FAD) are caused by any of over 150 mutations in three genes: the amyloid precursor protein (APP), presenilin 1 (PS1), and presenilin 2 (PS2). Mutant forms of PS1 have been shown to sensitize cells to apoptotic cell death. OBJECTIVE We investigated the effects of hypocapnia, a risk factor for both cognitive and neurodevelopment deficits, on caspase-3 activation, apoptosis, and amyloid beta-protein (Abeta) production, and assessed the influence of the PS1Delta9 FAD mutation on these effects. METHOD For this purpose, we exposed stably transfected H4 human neuroglioma cells to conditions consistent with hypocapnia (PCO2<40 mm Hg) and hypocapnia plus hypoxia (PO2<21%). RESULTS Hypocapnia (20 mm Hg CO2 for 6 h) induced caspase-3 activation and apoptosis; the PS1Delta9 FAD mutation significantly potentiated these effects. Moreover, the combination of hypocapnia (20 mm Hg CO2) and hypoxia (5%O2) induced caspase-3 activation and apoptosis in a synergistic manner. Hypocapnia (5 and 20 mm Hg CO2 for 6 h) also led to an increased Abeta production. CONCLUSION The findings suggest that hypocapnia (e.g. during general anesthesia) could exacerbate AD neuropathogenesis.
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Affiliation(s)
- Zhongcong Xie
- Genetics and Aging Research Unit, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Charlestown 02129-4404, USA
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Kohzuki M, Tomimatsu T, Fukuda H, Kanagawa T, Kanzaki T, Shimoya K, Murata Y. Long-term neuroprotective effects of carbon dioxide on neonatal rat hypoxic-ischemic brain injury: an experimental study of skilled motor tasks. Am J Obstet Gynecol 2006; 195:240-5. [PMID: 16681988 DOI: 10.1016/j.ajog.2005.12.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 11/23/2005] [Accepted: 12/19/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study was undertaken to investigate the long-term effect of hypercapnia on neonatal hypoxic-ischemic brain injury, we tested its effect in a neonatal rat hypoxia-ischemia model. STUDY DESIGN The rats were subjected to unilateral carotid artery ligation and exposure to 8% oxygen for 30 minutes. Six percent carbon dioxide was administered to the neonatal rats during unilateral hypoxia-ischemia, and the motor function and neurologic outcomes were determined 3 months later. RESULTS Significant motor functional improvement was observed in the hypercapnic animals, as judged by the Montoya staircase test. The unilateral brain injury was significantly ameliorated in the hypercapnic animals, and this amelioration was well correlated with the motor functional performance. Cerebral blood flow during hypoxia-ischemia, monitored by laser Doppler flowmetry, was better preserved in the hypercapnic animals. CONCLUSION Our results suggest that mild hypercapnia during hypoxia-ischemia may provide long-lasting motor functional as well as neurologic protection for immature brains, possibly by increasing cerebral blood flow during hypoxia.
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Affiliation(s)
- Masatomo Kohzuki
- Department of Obstetrics and Gynecology Osaka University Faculty of Medicine, Suita City, Osaka, Japan
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