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Kartal A, Robba C, Helmy A, Wolf S, Aries MJH. How to Define and Meet Blood Pressure Targets After Traumatic Brain Injury: A Narrative Review. Neurocrit Care 2024; 41:369-385. [PMID: 38982005 PMCID: PMC11377672 DOI: 10.1007/s12028-024-02048-5] [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: 02/14/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings. METHODS We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions. RESULTS Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury. DISCUSSION Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI. CONCLUSIONS We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials.
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Affiliation(s)
- Ahmet Kartal
- University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany.
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Sciences, University of Genoa, Genoa, Italy
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel J H Aries
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
- Institute of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
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Svedung Wettervik T, Hånell A, Lewén A, Enblad P. Should Patients with Traumatic Brain Injury with Significant Contusions be Treated with Different Neurointensive Care Targets? Neurocrit Care 2024; 41:511-522. [PMID: 38506969 PMCID: PMC11377649 DOI: 10.1007/s12028-024-01954-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/01/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) with large contusions make up a specific TBI subtype. Because of the risk of brain edema worsening, elevated cerebral perfusion pressure (CPP) may be particularly dangerous. The pressure reactivity index (PRx) and optimal cerebral perfusion pressure (CPPopt) are new promising perfusion targets based on cerebral autoregulation, but they reflect the global brain state and may be less valid in patients with predominant focal lesions. In this study, we aimed to investigate if patients with TBI with significant contusions exhibited a different association between PRx, CPP, and CPPopt in relation to functional outcome compared to those with small/no contusions. METHODS This observational study included 385 patients with moderate to severe TBI treated at a neurointensive care unit in Uppsala, Sweden. The patients were classified into two groups: (1) significant contusions (> 10 mL) and (2) small/no contusions (but with extra-axial or diffuse injuries). The percentage of good monitoring time (%GMT) with intracranial pressure > 20 mm Hg; PRx > 0.30; CPP < 60 mm Hg, within 60-70 mm Hg, or > 70 mm Hg; and ΔCPPopt less than - 5 mm Hg, ± 5 mm Hg, or > 5 mm Hg was calculated. Outcome (Glasgow Outcome Scale-Extended) was assessed after 6 months. RESULTS Among the 120 (31%) patients with significant contusions, a lower %GMT with CPP between 60 and 70 mm Hg was independently associated with unfavorable outcome. The %GMTs with PRx and ΔCPPopt ± 5 mm Hg were not independently associated with outcome. Among the 265 (69%) patients with small/no contusions, a higher %GMT of PRx > 0.30 and a lower %GMT of ΔCPPopt ± 5 mm Hg were independently associated with unfavorable outcome. CONCLUSIONS In patients with TBI with significant contusions, CPP within 60-70 mm Hg may improve outcome. PRx and CPPopt, which reflect global cerebral pressure autoregulation, may be useful in patients with TBI without significant focal brain lesions but seem less valid for those with large contusions. However, this was an observational, hypothesis-generating study; our findings need to be validated in prospective studies before translating them into clinical practice.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 PMCID: PMC11297425 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R. Mayer
- Mind Research Network, 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | | | - Joshua Marquez
- University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C. Stevenson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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Prasad A, Gilmore EJ, Kim JA, Begunova L, Olexa M, Beekman R, Falcone GJ, Matouk C, Ortega-Gutierrez S, Temkin NR, Barber J, Diaz-Arrastia R, de Havenon A, Petersen NH. Impact of Therapeutic Interventions on Cerebral Autoregulatory Function Following Severe Traumatic Brain Injury: A Secondary Analysis of the BOOST-II Study. Neurocrit Care 2024; 41:91-99. [PMID: 38158481 PMCID: PMC11285118 DOI: 10.1007/s12028-023-01896-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase II randomized controlled trial used a tier-based management protocol based on brain tissue oxygen (PbtO2) and intracranial pressure (ICP) monitoring to reduce brain tissue hypoxia after severe traumatic brain injury. We performed a secondary analysis to explore the relationship between brain tissue hypoxia, blood pressure (BP), and interventions to improve cerebral perfusion pressure (CPP). We hypothesized that BP management below the lower limit of autoregulation would lead to cerebral hypoperfusion and brain tissue hypoxia that could be improved with hemodynamic augmentation. METHODS Of the 119 patients enrolled in the Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase II trial, 55 patients had simultaneous recordings of arterial BP, ICP, and PbtO2. Autoregulatory function was measured by interrogating changes in ICP and PbtO2 in response to fluctuations in CPP using time-correlation analysis. The resulting autoregulatory indices (pressure reactivity index and oxygen reactivity index) were used to identify the "optimal" CPP and limits of autoregulation for each patient. Autoregulatory function and percent time with CPP outside personalized limits of autoregulation were calculated before, during, and after all interventions directed to optimize CPP. RESULTS Individualized limits of autoregulation were computed in 55 patients (mean age 38 years, mean monitoring time 92 h). We identified 35 episodes of brain tissue hypoxia (PbtO2 < 20 mm Hg) treated with CPP augmentation. Following each intervention, mean CPP increased from 73 ± 14 mm Hg to 79 ± 17 mm Hg (p = 0.15), and mean PbtO2 improved from 18.4 ± 5.6 mm Hg to 21.9 ± 5.6 mm Hg (p = 0.01), whereas autoregulatory function trended toward improvement (oxygen reactivity index 0.42 vs. 0.37, p = 0.14; pressure reactivity index 0.25 vs. 0.21, p = 0.2). Although optimal CPP and limits remained relatively unchanged, there was a significant decrease in the percent time with CPP below the lower limit of autoregulation in the 60 min after compared with before an intervention (11% vs. 23%, p = 0.05). CONCLUSIONS Our analysis suggests that brain tissue hypoxia is associated with cerebral hypoperfusion characterized by increased time with CPP below the lower limit of autoregulation. Interventions to increase CPP appear to improve autoregulation. Further studies are needed to validate the importance of autoregulation as a modifiable variable with the potential to improve outcomes.
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Affiliation(s)
- Ayush Prasad
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Emily J Gilmore
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Jennifer A Kim
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Liza Begunova
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Madelynne Olexa
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Rachel Beekman
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | | | - Nancy R Temkin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Adam de Havenon
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA
| | - Nils H Petersen
- Division of Neurocritical Care and Emergency, Department of Neurology, Yale University School of Medicine, 15 York St, LCI 1003, New Haven, CT, CT 06510, USA.
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Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Marquez I, Amenta F, Park K, Stein KY, Berrington N, Dhaliwal P, Zeiler FA. Optimal bispectral index exists in healthy patients undergoing general anesthesia: A validation study. J Clin Monit Comput 2024; 38:791-802. [PMID: 38436898 DOI: 10.1007/s10877-024-01136-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 02/05/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE Continuous cerebrovascular reactivity monitoring in both neurocritical and intra-operative care has gained extensive interest in recent years, as it has documented associations with long-term outcomes (in neurocritical care populations) and cognitive outcomes (in operative cohorts). This has sparked further interest into the exploration and evaluation of methods to achieve an optimal cerebrovascular reactivity measure, where the individual patient is exposed to the lowest insult burden of impaired cerebrovascular reactivity. Recent literature has documented, in neural injury populations, the presence of a potential optimal sedation level in neurocritical care, based on the relationship between cerebrovascular reactivity and quantitative depth of sedation (using bispectral index (BIS)) - termed BISopt. The presence of this measure outside of neural injury patients has yet to be proven. METHODS We explore the relationship between BIS and continuous cerebrovascular reactivity in two cohorts: (A) healthy population undergoing elective spinal surgery under general anesthesia, and (B) healthy volunteer cohort of awake controls. RESULTS We demonstrate the presence of BISopt in the general anesthesia population (96% of patients), and its absence in awake controls, providing preliminary validation of its existence outside of neural injury populations. Furthermore, we found BIS to be sufficiently separate from overall systemic blood pressure, this indicates that they impact different pathophysiological phenomena to mediate cerebrovascular reactivity. CONCLUSIONS Findings here carry implications for the adaptation of the individualized physiologic BISopt concept to non-neural injury populations, both within critical care and the operative theater. However, this work is currently exploratory, and future work is required.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Izabella Marquez
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Kangyun Park
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Neil Berrington
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Perry Dhaliwal
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
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Hong E, Froese L, Pontén E, Fletcher-Sandersjöö A, Tatter C, Hammarlund E, Åkerlund CAI, Tjerkaski J, Alpkvist P, Bartek J, Raj R, Lindblad C, Nelson DW, Zeiler FA, Thelin EP. Critical thresholds of long-pressure reactivity index and impact of intracranial pressure monitoring methods in traumatic brain injury. Crit Care 2024; 28:256. [PMID: 39075480 PMCID: PMC11285281 DOI: 10.1186/s13054-024-05042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/16/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Moderate-to-severe traumatic brain injury (TBI) has a global mortality rate of about 30%, resulting in acquired life-long disabilities in many survivors. To potentially improve outcomes in this TBI population, the management of secondary injuries, particularly the failure of cerebrovascular reactivity (assessed via the pressure reactivity index; PRx, a correlation between intracranial pressure (ICP) and mean arterial blood pressure (MAP)), has gained interest in the field. However, derivation of PRx requires high-resolution data and expensive technological solutions, as calculations use a short time-window, which has resulted in it being used in only a handful of centers worldwide. As a solution to this, low resolution (longer time-windows) PRx has been suggested, known as Long-PRx or LPRx. Though LPRx has been proposed little is known about the best methodology to derive this measure, with different thresholds and time-windows proposed. Furthermore, the impact of ICP monitoring on cerebrovascular reactivity measures is poorly understood. Hence, this observational study establishes critical thresholds of LPRx associated with long-term functional outcome, comparing different time-windows for calculating LPRx as well as evaluating LPRx determined through external ventricular drains (EVD) vs intraparenchymal pressure device (IPD) ICP monitoring. METHODS The study included a total of n = 435 TBI patients from the Karolinska University Hospital. Patients were dichotomized into alive vs. dead and favorable vs. unfavorable outcomes based on 1-year Glasgow Outcome Scale (GOS). Pearson's chi-square values were computed for incrementally increasing LPRx or ICP thresholds against outcome. The thresholds that generated the greatest chi-squared value for each LPRx or ICP parameter had the highest outcome discriminatory capacity. This methodology was also completed for the segmentation of the population based on EVD, IPD, and time of data recorded in hospital stay. RESULTS LPRx calculated with 10-120-min windows behaved similarly, with maximal chi-square values ranging at around a LPRx of 0.25-0.35, for both survival and favorable outcome. When investigating the temporal relations of LPRx derived thresholds, the first 4 days appeared to be the most associated with outcomes. The segmentation of the data based on intracranial monitoring found limited differences between EVD and IPD, with similar LPRx values around 0.3. CONCLUSION Our work suggests that the underlying prognostic factors causing impairment in cerebrovascular reactivity can, to some degree, be detected using lower resolution PRx metrics (similar found thresholding values) with LPRx found clinically using as low as 10 min-by-minute samples of MAP and ICP. Furthermore, EVD derived LPRx with intermittent cerebrospinal fluid draining, seems to present similar outcome capacity as IPD. This low-resolution low sample LPRx method appears to be an adequate substitute for the clinical prognostic value of PRx and may be implemented independent of ICP monitoring method when PRx is not feasible, though further research is warranted.
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Affiliation(s)
- Erik Hong
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Logan Froese
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.
| | - Emeli Pontén
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Alexander Fletcher-Sandersjöö
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Charles Tatter
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Södersjukhuset, Stockholm, Sweden
| | - Emma Hammarlund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia A I Åkerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Peter Alpkvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Bartek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki, Helsinki, Finland
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Frederick A Zeiler
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Moss L, Shaw M, Piper I, Hawthorne C. From bed to bench and back again: Challenges facing deployment of intracranial pressure data analysis in clinical environments. BRAIN & SPINE 2024; 4:102858. [PMID: 39105104 PMCID: PMC11298855 DOI: 10.1016/j.bas.2024.102858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 05/29/2024] [Accepted: 07/03/2024] [Indexed: 08/07/2024]
Abstract
Introduction Numerous complex physiological models derived from intracranial pressure (ICP) monitoring data have been developed. More recently, techniques such as machine learning are being used to develop increasingly sophisticated models to aid in clinical decision-making tasks such as diagnosis and prediction. Whilst their potential clinical impact may be significant, few models based on ICP data are routinely available at a patient's bedside. Further, the ability to refine models using ongoing patient data collection is rare. In this paper we identify and discuss the challenges faced when converting insight from ICP data analysis into deployable tools at the patient bedside. Research question To provide an overview of challenges facing implementation of sophisticated ICP models and analyses at the patient bedside. Material and methods A narrative review of the barriers facing implementation of sophisticated ICP models and analyses at the patient bedside in a neurocritical care unit combined with a descriptive case study (the CHART-ADAPT project) on the topic. Results Key barriers found were technical, analytical, and integrity related. Examples included: lack of interoperability of medical devices for data collection and/or model deployment; inadequate infrastructure, hindering analysis of large volumes of high frequency patient data; a lack of clinical confidence in a model; and ethical, trust, security and patient confidentiality considerations governing the secondary use of patient data. Discussion and conclusion To realise the benefits of ICP data analysis, the results need to be promptly delivered and meaningfully communicated. Multiple barriers to implementation remain and solutions which address real-world challenges are required.
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Affiliation(s)
- Laura Moss
- Dept. of Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Martin Shaw
- Dept. of Clinical Physics, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
- College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ian Piper
- College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Christopher Hawthorne
- Dept. of Neuroanaesthesia, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
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Patel PP, Egodage T, Martin MJ. All Over the MAP! Cerebral Autoregulation and Optimizing Brain Tissue Oxygenation After Traumatic Brain Injury. Crit Care Med 2024; 52:1166-1169. [PMID: 38869395 DOI: 10.1097/ccm.0000000000006249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Purvi P Patel
- Department of Surgery, Loyola University Medical Center, Chicago, IL
| | - Tanya Egodage
- Department of Surgery, Cooper University Hospital, Camden, NJ
| | - Matthew J Martin
- Division of Trauma and Acute Care Surgery, Department of Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA
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Kempen B, Depreitere B, Piper I, Sahuquillo J, Mircea Iencean S, Krishnan Kanthimathinathan H, Zipfel J, Barzdina A, Pezzato S, Jones PA, Lo TYM. Visualization of the Intracranial Pressure and Time Burden in Childhood Brain Trauma: What We Have Learned One Decade on With KidsBrainIT. J Neurotrauma 2024; 41:e1651-e1659. [PMID: 38425208 DOI: 10.1089/neu.2023.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
To validate the intracranial pressure (ICP) dose-response visualization plot for the first time in a novel prospectively collected pediatric traumatic brain injury (pTBI) data set from the multi-center, multi-national KidsBrainIT consortium. Prospectively collected minute-by-minute ICP and mean arterial blood pressure time series of 104 pTBI patients were categorized in ICP intensity-duration episodes. These episodes were correlated with the 6-month Glasgow Outcome Score (GOS) and displayed in a color-coded ICP dose-response plot. The influence of cerebrovascular reactivity and cerebral perfusion pressure (CPP) were investigated. The generated ICP dose-response plot on the novel data set was similar to the previously published pediatric plot. This study confirmed that higher ICP episodes were tolerated for a shorter duration of time, with an approximately exponential decay curve delineating the positive and negative association zones. ICP above 20 mm Hg for any duration in time was associated with poor outcome in our patients. Cerebrovascular reactivity state did not influence their respective transition curves above 10 mm Hg ICP. CPP below 50 mm Hg was not tolerated, regardless of ICP and duration, and was associated with worse outcome. The ICP dose-response plot was reproduced in a novel and independent pTBI data set. ICP above 20 mm Hg and CPP below 50 mm Hg for any duration in time were associated with worse outcome. This highlighted a pressing need to reduce pediatric ICP therapeutic thresholds used at the bedside.
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Affiliation(s)
- Bavo Kempen
- Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosciences, KU Leuven, Leuven, Belgium
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Ian Piper
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Pediatric Critical Care Unit, Royal Hospital for Children & Young People, Edinburgh, United Kingdom
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Stefan Mircea Iencean
- Department of Neurosurgery, GrT Popa University of Medicine and Pharmacy, Iasi, Romania
| | | | - Julian Zipfel
- Department of Neurosurgery, Section Pediatric Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Arta Barzdina
- Clinic for Anesthesiology and Intensive Care, Children's Clinical University Hospital, Riga, Latvia
| | - Stefano Pezzato
- Neonatal and Pediatric Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Patricia A Jones
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Tsz-Yan Milly Lo
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Pediatric Critical Care Unit, Royal Hospital for Children & Young People, Edinburgh, United Kingdom
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10
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Klein SP, Decraene B, De Sloovere V, Kempen B, Meyfroidt G, Depreitere B. The Pressure Reactivity Index as a Measure for Cerebrovascular Autoregulation: Validation in a Porcine Cranial Window Model. Neurosurgery 2024:00006123-990000000-01207. [PMID: 38861643 DOI: 10.1227/neu.0000000000003019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/09/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pressure reactivity index (PRx) has been proposed as a metric associated with cerebrovascular autoregulatory (CA) function and has been thoroughly investigated in clinical research. In this study, PRx is validated in a porcine cranial window model, developed to visualize pial arteriolar autoregulation and its limits. METHODS We measured arterial blood pressure, intracranial pressure, pial arteriolar diameter, and red blood cell (RBC) velocity in a closed cranial window piglet model during gradual balloon catheter-induced arterial hypotension (n = 10) or hypertension (n = 10). CA limits were derived through piecewise linear regression of calculated RBC flux vs cerebral perfusion pressure (CPP), leading for each arteriole to 1 lower limit of autoregulation (LLA) and 2 upper limits of autoregulation (ULA1 and ULA2). Autoregulation limits were compared with PRx thresholds, and receiver operating curve analysis was performed with and without CPP binning. A linear mixed effects model of PRx was performed. RESULTS Receiver operating curve analysis indicated an area under the curve (AUC) for LLA prediction by a PRx of 0.65 (95% CI: 0.64-0.67) and 0.77 (95% CI: 0.69-0.86) without and with CPP binning, respectively. The AUC for ULA1 prediction by PRx was 0.69 (95% CI: 0.68-0.69) without and 0.75 (95% CI: 0.68-0.82) with binning. The AUC for ULA2 prediction was 0.55 (95% CI: 0.55-0.58) without and 0.63 (95% CI 0.53-0.72) with binning. The sensitivity and specificity of binned PRx were 65%/90% for LLA, 69%/71% for ULA1, and 59%/74% for ULA2, showing wide interindividual variability. In the linear mixed effects model, pial arteriolar diameter changes were significantly associated with PRx changes (P = .002), whereas RBC velocity (P = .28) and RBC flux (P = .24) were not. CONCLUSION We conclude that PRx is predominantly determined by pial arteriolar diameter changes and moderately predicts CA limits. Performance to detect the CA limits varied highly on an individual level. Active therapeutic strategies based on PRx and the associated correlation metrics should incorporate these limitations.
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Affiliation(s)
- Samuel P Klein
- Neurosurgery Center Limburg, Jessa Hospital, Hasselt, Belgium
| | | | | | - Bavo Kempen
- Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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11
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Gritti P, Bonfanti M, Zangari R, Bonanomi E, Farina A, Pezzetti G, Pelliccioli I, Longhi L, Di Matteo M, Viscone A, Lando G, Cavalleri G, Gerevini S, Biroli F, Lorini FL. Cerebral autoregulation in traumatic brain injury: ultra-low-frequency pressure reactivity index and intracranial pressure across age groups. Crit Care 2024; 28:33. [PMID: 38263241 PMCID: PMC10807228 DOI: 10.1186/s13054-024-04814-5] [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: 11/26/2023] [Accepted: 01/18/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The ultra-low-frequency pressure reactivity index (UL-PRx) has been established as a surrogate method for bedside estimation of cerebral autoregulation (CA). Although this index has been shown to be a predictor of outcome in adult and pediatric patients with traumatic brain injury (TBI), a comprehensive evaluation of low sampling rate data collection (0.0033 Hz averaged over 5 min) on cerebrovascular reactivity has never been performed. OBJECTIVE To evaluate the performance and predictive power of the UL-PRx for 12-month outcome measures, alongside all International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) models and in different age groups. To investigate the potential for optimal cerebral perfusion pressure (CPPopt). METHODS Demographic data, IMPACT variables, in-hospital mortality, and Glasgow Outcome Scale Extended (GOSE) at 12 months were extracted. Filtering and processing of the time series and creation of the indices (cerebral intracranial pressure (ICP), cerebral perfusion pressure (CPP), UL-PRx, and deltaCPPopt (ΔCPPopt and CPPopt-CPP)) were performed using an in-house algorithm. Physiological parameters were assessed as follows: mean index value, % time above threshold, and mean hourly dose above threshold. RESULTS A total of 263 TBI patients were included: pediatric (17.5% aged ≤ 16 y) and adult (60.5% aged > 16 and < 70 y and 22.0% ≥ 70 y, respectively) patients. In-hospital and 12-month mortality were 25.9% and 32.7%, respectively, and 60.0% of patients had an unfavorable outcome at 12 months (GOSE). On univariate analysis, ICP, CPP, UL-PRx, and ΔCPPopt were associated with 12-month outcomes. The cutoff of ~ 20-22 for mean ICP and of ~ 0.30 for mean UL-PRx were confirmed in all age groups, except in patients older than 70 years. Mean UL-PRx remained significantly associated with 12-month outcomes even after adjustment for IMPACT models. This association was confirmed in all age groups. UL-PRx resulted associate with CPPopt. CONCLUSIONS The study highlights UL-PRx as a tool for assessing CA and valuable outcome predictor for TBI patients. The results emphasize the potential clinical utility of the UL-PRx and its adaptability across different age groups, even after adjustment for IMPACT models. Furthermore, the correlation between UL-PRx and CPPopt suggests the potential for more targeted treatment strategies. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05043545, principal investigator Paolo Gritti, date of registration 2021.08.21.
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Affiliation(s)
- Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Marco Bonfanti
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessia Farina
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giulio Pezzetti
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Isabella Pelliccioli
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luca Longhi
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Maria Di Matteo
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andrea Viscone
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Gabriele Lando
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Gaia Cavalleri
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Simonetta Gerevini
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Biroli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ferdinando Luca Lorini
- Department of Anesthesia and Critical Care Medicine, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
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12
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Tabone L, El-Tannoury J, Levy M, Sauthier M, Joram N, Du Pont-Thibodeau G, Bourgoin P, Al-Omar S, Poirier N, Emeriaud G, Thibault C. Determining Optimal Mean Arterial Blood Pressure Based on Cerebral Autoregulation in Children after Cardiac Surgery. Pediatr Cardiol 2024; 45:81-91. [PMID: 37945783 DOI: 10.1007/s00246-023-03326-3] [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: 05/26/2023] [Accepted: 10/10/2023] [Indexed: 11/12/2023]
Abstract
To evaluate the feasibility of continuous determination of the optimal mean arterial blood pressure (opt-MAP) according to cerebral autoregulation and to describe the opt-MAP, the autoregulation limits, and the time spent outside these limits in children within 48 h of cardiac surgery. Cerebral autoregulation was assessed using the correlation coefficient (COx) between cerebral oxygenation and MAP in children following cardiac surgery. Plots depicting the COx according to the MAP were used to determine the opt-MAP using weighted multiple time windows. For each patient, we estimated (1) the time spent with MAP outside the autoregulation limits and (2) the burden of deviation, defined as the area between the MAP curve and the autoregulation limits when the MAP was outside these limits. Fifty-one patients with a median age of 7.1 (IQR 0.7-52.0) months old were included. The opt-MAP was calculated for 94% (IQR 90-96) of the monitored time. The opt-MAP was significantly lower in neonates < 1 month old. The patients spent 24% (18-31) of the time outside of the autoregulation limits, with no significant differences between age groups. Continuous determination of the opt-MAP is feasible in children within the first 48 h following cardiac surgery.
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Affiliation(s)
- Laurence Tabone
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Pediatric Intensive Care Unit and Pediatric Emergency Department, CHU Clocheville, Tours, France
| | - Jihad El-Tannoury
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Michael Levy
- Pediatric Intensive Care Unit, CHU Robert Debré, Paris, France
| | - Michael Sauthier
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Nicolas Joram
- Pediatric Intensive Care Unit, CHU de Nantes, Nantes, France
| | - Geneviève Du Pont-Thibodeau
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, CHU de Nantes, Nantes, France
| | - Sally Al-Omar
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Nancy Poirier
- Department of Cardiac Surgery, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Emeriaud
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Céline Thibault
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
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13
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Froese L, Hammarlund E, Åkerlund CAI, Tjerkaski J, Hong E, Lindblad C, Nelson DW, Thelin EP, Zeiler FA. The impact of sedative and vasopressor agents on cerebrovascular reactivity in severe traumatic brain injury. Intensive Care Med Exp 2023; 11:54. [PMID: 37541993 PMCID: PMC10403459 DOI: 10.1186/s40635-023-00524-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/17/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND The aim of this study is to evaluate the impact of commonly administered sedatives (Propofol, Alfentanil, Fentanyl, and Midazolam) and vasopressor (Dobutamine, Ephedrine, Noradrenaline and Vasopressin) agents on cerebrovascular reactivity in moderate/severe TBI patients. Cerebrovascular reactivity, as a surrogate for cerebral autoregulation was assessed using the long pressure reactivity index (LPRx). We evaluated the data in two phases, first we assessed the minute-by-minute data relationships between different dosing amounts of continuous infusion agents and physiological variables using boxplots, multiple linear regression and ANOVA. Next, we assessed the relationship between continuous/bolus infusion agents and physiological variables, assessing pre-/post- dose of medication change in physiology using a Wilcoxon signed-ranked test. Finally, we evaluated sub-groups of data for each individual dose change per medication, focusing on key physiological thresholds and demographics. RESULTS Of the 475 patients with an average stay of 10 days resulting in over 3000 days of recorded information 367 (77.3%) were male with a median Glasgow coma score of 7 (4-9). The results of this retrospective observational study confirmed that the infusion of most administered agents do not impact cerebrovascular reactivity, which is confirmed by the multiple linear regression components having p value > 0.05. Incremental dose changes or bolus doses in these medications in general do not lead to significant changes in cerebrovascular reactivity (confirm by Wilcoxon signed-ranked p value > 0.05 for nearly all assessed relationships). Within the sub-group analysis that separated the data based on LPRx pre-dose, a significance between pre-/post-drug change in LPRx was seen, however this may be more of a result from patient state than drug impact. CONCLUSIONS Overall, this study indicates that commonly administered agents with incremental dosing changes have no clinically significant influence on cerebrovascular reactivity in TBI (nor do they impair cerebrovascular reactivity). Though further investigation in a larger and more diverse TBI patient population is required.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Emma Hammarlund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia A I Åkerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jonathan Tjerkaski
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Erik Hong
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
- Centre On Aging, University of Manitoba, Winnipeg, Canada.
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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14
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Yu Y, Gong Y, Hu B, Ouyang B, Pan A, Liu J, Liu F, Shang XL, Yang XH, Tu G, Wang C, Ma S, Fang W, Liu L, Liu J, Chen D. Expert consensus on blood pressure management in critically ill patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:185-203. [PMID: 37533806 PMCID: PMC10391579 DOI: 10.1016/j.jointm.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/02/2023] [Accepted: 06/08/2023] [Indexed: 08/04/2023]
Affiliation(s)
- Yuetian Yu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200001, China
| | - Ye Gong
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bo Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bin Ouyang
- Department of Critical Care Medicine, The First Affiliated Hospital of SunYatsen University, Guangzhou 510080, Guangdong, China
| | - Aijun Pan
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, Anhui, China
| | - Jinglun Liu
- Department of Emergency Medicine and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fen Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330000, Jiangxi, China
| | - Xiu-Ling Shang
- Department of Critical Care Medicine, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Center for Critical Care Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fuzhou 350001 Fujian, China
| | - Xiang-Hong Yang
- Department of Intensive Care Unit, Emergency & Intensive Care Unit Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou 310014 Zhejiang, China
| | - Guowei Tu
- Cardiac Intensive Care Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Changsong Wang
- Department of Critical Care Medicine, the First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Wei Fang
- Department of Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong First Medical University, Jinan, 250014 Shandong, China
| | - Ling Liu
- Department of Critical Care Medicine, Jiangsu Provincial Key Laboratory of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 Jiangsu, China
| | - Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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15
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Gritti P, Bonfanti M, Zangari R, Farina A, Longhi L, Rasulo FA, Bertuetti R, Biroli A, Biroli F, Lorini FL. Evaluation and Application of Ultra-Low-Resolution Pressure Reactivity Index in Moderate or Severe Traumatic Brain Injury. J Neurosurg Anesthesiol 2023; 35:313-321. [PMID: 35499152 DOI: 10.1097/ana.0000000000000847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pressure reactivity index (PRx) has emerged as a surrogate method for the continuous bedside estimation of cerebral autoregulation and a predictor of unfavorable outcome after traumatic brain injury (TBI). However, calculation of PRx require continuous high-resolution monitoring currently limited to specialized intensive care units. The aim of this study was to evaluate a new index, the ultra-low-frequency PRx (UL-PRx) sampled at ∼0.0033 Hz at ∼5 minutes periods, and to investigate its association with outcome. METHODS Demographic data, admission Glasgow coma scale, in-hospital mortality and Glasgow outcome scale extended at 12 months were extracted from electronic records. The filtering and preparation of time series of intracranial pressure (ICP), mean arterial pressure and cerebral perfusion pressure (CPP), and calculation of the indices (UL-PRx, Δ-optimal CPP), were performed in MATLAB using an in-house algorithm. RESULTS A total of 164 TBI patients were included in the study; in-hospital and 12-month mortality was 29.3% and 38.4%, respectively, and 64% of patients had poor neurological outcome at 12 months. On univariate analysis, ICP, CPP, UL-PRx, and ΔCPPopt were associated with 12-month mortality. After adjusting for age, Glasgow coma scale, ICP and CPP, mean UL-PRx and UL-PRx thresholds of 0 and +0.25 remained associated with 12-month mortality. Similar findings were obtained for in-hospital mortality. For mean UL-PRx, the area under the receiver operating characteristic curves for in-hospital and 12-month mortality were 0.78 (95% confidence interval [CI]: 0.69-0.87; P <0.001) and 0.70 (95% CI: 0.61-0.79; P <0.001), respectively, and 0.65 (95% CI: 0.57-0.74; P =0.001) for 12-month neurological outcome. CONCLUSIONS Our findings indicate that ultra-low-frequency sampling might provide sufficient resolution to derive information about the state of cerebrovascular autoregulation and prediction of 12-month outcome in TBI patients.
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Affiliation(s)
- Paolo Gritti
- Department of Anesthesia and Critical Care Medicine
| | | | - Rosalia Zangari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo
| | | | - Luca Longhi
- Department of Anesthesia and Critical Care Medicine
| | - Frank A Rasulo
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Bertuetti
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Biroli
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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16
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Froese L, Sainbhi AS, Gomez A, Marquez I, Amenta F, Batson C, Stein KY, Zeiler FA. Discrete Fourier Transform Windowing Techniques for Cerebral Physiological Research in Neural Injury: A Practical Demonstration. Neurotrauma Rep 2023; 4:410-419. [PMID: 37360544 PMCID: PMC10288301 DOI: 10.1089/neur.2022.0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
To optimally assess oscillatory phenomena within physiological variables, spectral domain transforms are used. A discrete Fourier transform (DFT) is one of the most common methods used to attain this spectral change. In traumatic brain injury (TBI), a DFT is used to derive more complicated methods of physiological assessment, particularly that of cerebrovascular reactivity (CVR). However, a practical application of a DFT will introduce various errors that need to be considered. This study will evaluate the pulse amplitude DFT derivation of intracranial pressure (AMP) to highlight how slight differences in DFT methodologies can impact calculations. Utilizing a high-frequency prospectively maintained data set of TBI patients with recorded arterial and intracranial blood pressure, various cerebral physiological aspects of interest were assessed using the DFT windowing methods of rectangular, Hanning, and Chebyshev. These included AMP, CVR indices (including the pressure reactivity and pulse amplitude index), and the optimal cerebral perfusion pressure (with all methods of CVR). The results of the different DFT-derived windowing methods were compared using the Wilcoxon signed-ranked test and histogram plots between individual patients and over the whole 100-patient cohort. The results for this analysis demonstrate that, overall and for grand average values, there were limited differences between the different DFT windowing techniques. However, there were individual patient outliers to whom the different methods resulted in noticeably different overall values. From this information, for derived indices utilizing a DFT in the assessment of AMP, there are limited differences within the resulting calculations for larger aggregates of data. However, when the amplitude of spectrally resolved response is important and needs to be robust in smaller moments in time, it is recommended to use a window that has amplitude accuracy (such as Chebyshev or flat-top).
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Izzy Marquez
- Undergraduate Engineering Program, Department of Biosystems Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Fiorella Amenta
- Undergraduate Engineering Program, Department of Biosystems Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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17
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Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Marquez I, Amenta F, Stein KY, Zeiler FA. Temporal relationship between vasopressor and sedative administration and cerebrovascular response in traumatic brain injury: a time-series analysis. Intensive Care Med Exp 2023; 11:30. [PMID: 37246179 DOI: 10.1186/s40635-023-00515-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/21/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Although vasopressor and sedative agents are commonly used within the intensive care unit to mediate systemic and cerebral physiology, the full impact such agents have on cerebrovascular reactivity remains unclear. Using a prospectively maintained database of high-resolution critical care and physiology, the time-series relationship between vasopressor/sedative administration, and cerebrovascular reactivity was interrogated. Cerebrovascular reactivity was assessed through intracranial pressure and near infrared spectroscopy measures. Using these derived measures, the relationship between hourly dose of medication and hourly index values could be evaluated. The individual medication dose change and their corresponding physiological response was compared. Given the high number of doses of propofol and norepinephrine, a latent profile analysis was used to identify any underlying demographic or variable relationships. Finally, using time-series methodologies of Granger causality and vector impulse response functions, the relationships between the cerebrovascular reactivity derived variables were compared. RESULTS From this retrospective observational study of 103 TBI patients, the evaluation between the changes in vasopressor or sedative agent dosing and the previously described cerebral physiologies was completed. The assessment of the physiology pre/post infusion agent change resulted in similar overall values (Wilcoxon signed-ranked p value > 0.05). Time series methodologies demonstrated that the basic physiological relationships were identical before and after an infusion agent was changed (Granger causality demonstrated the same directional impact in over 95% of the moments, with response function being graphically identical). CONCLUSIONS This study suggests that overall, there was a limited association between the changes in vasopressor or sedative agent dosing and the previously described cerebral physiologies including that of cerebrovascular reactivity. Thus, current regimens of administered sedative and vasopressor agents appear to have little to no impact on cerebrovascular reactivity in TBI.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Izabella Marquez
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Centre on Aging, University of Manitoba, Winnipeg, Canada
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18
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Yue JK, Deng H. Traumatic Brain Injury: Contemporary Challenges and the Path to Progress. J Clin Med 2023; 12:jcm12093283. [PMID: 37176723 PMCID: PMC10179594 DOI: 10.3390/jcm12093283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide, and its incidence is increasing [...].
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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19
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Beqiri E, Ercole A, Aries MJH, Placek MM, Tas J, Czosnyka M, Stocchetti N, Smielewski P. Towards autoregulation-oriented management after traumatic brain injury: increasing the reliability and stability of the CPPopt algorithm. J Clin Monit Comput 2023:10.1007/s10877-023-01009-1. [PMID: 37119323 PMCID: PMC10371880 DOI: 10.1007/s10877-023-01009-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/01/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE CPPopt denotes a Cerebral Perfusion Pressure (CPP) value at which the Pressure-Reactivity index, reflecting the global state of Cerebral Autoregulation, is best preserved. CPPopt has been investigated as a potential dynamically individualised CPP target in traumatic brain injury patients admitted in intensive care unit. The prospective bedside use of the concept requires ensured safety and reliability of the CPP recommended targets based on the automatically-generated CPPopt. We aimed to: Increase stability and reliability of the CPPopt automated algorithm by fine-tuning; perform outcome validation of the adjusted algorithm in a multi-centre TBI cohort. METHODS ICM + software was used to derive CPPopt and fine-tune the algorithm. Parameters for improvement of the algorithm were selected based on qualitative and quantitative assessment of stability and reliability metrics. Patients enrolled in the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution cohort were included for retrospective validation. Yield and stability of the new algorithm were compared to the previous algorithm using Mann-U test. Area under the curves for mortality prediction at 6 months were compared with the DeLong Test. RESULTS CPPopt showed higher stability (p < 0.0001), but lower yield compared to the previous algorithm [80.5% (70-87.5) vs 85% (75.7-91.2), p < 0.001]. Deviation of CPPopt could predict mortality with an AUC of [AUC = 0.69 (95% CI 0.59-0.78), p < 0.001] and was comparable with the previous algorithm. CONCLUSION The CPPopt calculation algorithm was fine-tuned and adapted for prospective use with acceptable lower yield, improved stability and maintained prognostic power.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Marcel J H Aries
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Nino Stocchetti
- Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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20
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Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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21
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Gritti P, Bonfanti M, Zangari R, Bonanomi E, Pellicioli I, Mandelli P, Longhi L, Rasulo FA, Bertuetti R, Farina A, Biroli F, Lorini FL. Evaluation and application of ultra-low-frequency pressure reactivity index in pediatric traumatic brain injury patients. Acta Neurochir (Wien) 2023; 165:865-874. [PMID: 36847979 DOI: 10.1007/s00701-023-05538-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/18/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE While clinical practice suggests that knowing the cerebral autoregulation (CA) status of traumatic brain injury (TBI) patients is crucial in assessing the best treatment, evidence in pediatric TBI (pTBI) is limited. The pressure reactivity index (PRx) is a surrogate method for the continuous estimation of CA in adults; however, calculations require continuous, high-resolution monitoring data. We evaluate an ultra-low-frequency pressure reactivity index (UL-PRx), based on data sampled at ∼5-min periods, and test its association with 6-month mortality and unfavorable outcome in a cohort of pTBI patients. METHODS Data derived from pTBI patients (0-18 years) requiring intracranial pressure (ICP) monitoring were retrospectively collected and processed in MATLAB using an in-house algorithm. RESULTS Data on 47 pTBI patients were included. UL-PRx mean values, ICP, cerebral perfusion pressure (CPP), and derived indices showed significant association with 6-month mortality and unfavorable outcome. A value of UL-PRx of 0.30 was identified as the threshold to better discriminate both surviving vs deceased patients (AUC: 0.90), and favorable vs unfavorable outcomes (AUC: 0.70) at 6 months. At multivariate analysis, mean UL-PRx and % time with ICP > 20 mmHg, remained significantly associated with 6-month mortality and unfavorable outcome, even when adjusted for International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-Core variables. In six patients undergoing secondary decompressive craniectomy, no significant changes in UL-PRx were found after surgery. CONCLUSIONS UL-PRx is associated with a 6-month outcome even if adjusted for IMPACT-Core. Its application in pediatric intensive care unit could be useful to evaluate CA and offer possible prognostic and therapeutic implications in pTBI patients. CLINICALTRIALS GOV: NCT05043545, September 14, 2021, retrospectively registered.
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Affiliation(s)
- Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Marco Bonfanti
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Isabella Pellicioli
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Pietro Mandelli
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luca Longhi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Frank A Rasulo
- Anesthesiology, Intensive Care and Emergency Medicine, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Bertuetti
- Anesthesiology, Intensive Care and Emergency Medicine, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessia Farina
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Biroli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ferdinando Luca Lorini
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
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22
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Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Marquez I, Amenta F, Park K, Stein KY, Thelin EP, Zeiler FA. Cerebrovascular Reactivity Is Not Associated With Therapeutic Intensity in Adult Traumatic Brain Injury: A Validation Study. Neurotrauma Rep 2023; 4:307-317. [PMID: 37187506 PMCID: PMC10181802 DOI: 10.1089/neur.2023.0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Within traumatic brain injury (TBI) care, there is growing interest in pathophysiological markers as surrogates of disease severity, which may be used to improve and individualize care. Of these, assessment of cerebrovascular reactivity (CVR) has been extensively studied given that it is a consistent, independent factor associated with mortality and functional outcome. However, to date, the literature supports little-to-no impact of current guideline-supported therapeutic interventions on continuously measured CVR. Previous work in this area has suffered from a lack of validation studies, given the rarity of time-matched high-frequency cerebral physiology with serially recorded therapeutic interventions; thus, we undertook a validation study. Utilizing the Winnipeg Acute TBI database, we evaluated the association between daily treatment intensity levels, as measured through the therapeutic intensity level (TIL) scoring system, and continuous multi-modal-derived CVR measures. CVR measures included the intracranial pressure (ICP)-derived pressure reactivity index, pulse amplitude index, and RAC index (a correlation between the pulse amplitude of ICP and cerebral perfusion pressure), as well as the cerebral autoregulation measure of near-infrared spectroscopy-based cerebral oximetry index. These measures were also derived over a key threshold for each day and were compared to the daily total TIL measure. In summary, we could not observe any overall relationship between TIL and these CVR measures. This validates previous findings and represents only the second such analysis to date. This helps to confirm that CVR appears to remain independent of current therapeutic interventions and is a potential unique physiological target for critical care. Further work into the high-frequency relationship between critical care and CVR is required.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Address correspondence to: Logan Froese, BSc (Eng), Biomedical Engineering, Faculty of Engineering, University of Manitoba, 75 Chancellor's Circle, Winnipeg, Manitoba R3T 5V6, Canada;
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Izzy Marquez
- Undergraduate Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kangyun Park
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric P. Thelin
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Frederick A. Zeiler
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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23
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 127.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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Froese L, Gomez A, Sainbhi AS, Batson C, Slack T, Stein KY, Mathieu F, Zeiler FA. Optimal bispectral index level of sedation and cerebral oximetry in traumatic brain injury: a non-invasive individualized approach in critical care? Intensive Care Med Exp 2022; 10:33. [PMID: 35962913 PMCID: PMC9375800 DOI: 10.1186/s40635-022-00460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Impaired cerebral autoregulation has been linked with worse outcomes, with literature suggesting that current therapy guidelines fail to significantly impact cerebrovascular reactivity. The cerebral oximetry index (COx_a) is a surrogate measure of cerebrovascular reactivity which can in theory be obtained non-invasively using regional brain tissue oxygen saturation and arterial blood pressure. The goal of this study was to assess the relationship between objectively measured depth of sedation through BIS and autoregulatory capacity measured through COx_a. Methods In a prospectively maintained observational study, we collected continuous regional brain tissue oxygen saturation, intracranial pressure, arterial blood pressure and BIS in traumatic brain injury patients. COx_a was obtained using the Pearson’s correlation between regional brain tissue oxygen saturation and arterial blood pressure and ranges from − 1 to 1 with higher values indicating impairment of cerebrovascular reactivity. Using BIS values and COx_a, a curve-fitting method was applied to determine the minimum value for the COx_a. The associated BIS value with the minimum COx_a is called BISopt. This BISopt was both visually and algorithmically determined, which were compared and assessed over the whole dataset. Results Of the 42 patients, we observed that most had a parabolic relationship between BIS and COx_a. This suggests a potential “optimal” depth of sedation where COx_a is the most intact. Furthermore, when comparing the BISopt algorithm with visual inspection of BISopt, we obtained similar results. Finally, BISopt % yield (determined algorithmically) appeared to be independent from any individual sedative or vasopressor agent, and there was agreement between BISopt found with COx_a and the pressure reactivity index (another surrogate for cerebrovascular reactivity). Conclusions This study suggests that COx_a is capable of detecting disruption in cerebrovascular reactivity which occurs with over-/under-sedation, utilizing a non-invasive measure of determination and assessment. This technique may carry implications for tailoring sedation in patients, focusing on individualized neuroprotection. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00460-9.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Trevor Slack
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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25
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Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
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Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
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26
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Kirschen MP, Majmudar T, Diaz-Arrastia R, Berg R, Abella BS, Topjian A, Balu R. Deviations from PRx-derived optimal blood pressure are associated with mortality after cardiac arrest. Resuscitation 2022; 175:81-87. [PMID: 35276311 PMCID: PMC9135307 DOI: 10.1016/j.resuscitation.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 01/18/2023]
Abstract
AIM Pressure reactivity index (PRx) provides a surrogate measurement of cerebrovascular autoregulation (CAR). We determined whether deviations from PRx-derived optimal mean arterial pressure (MAPopt) were associated with in-hospital mortality after adult cardiac arrest. METHODS Retrospective analysis of post-cardiac arrest patients who had continuously recorded intracranial pressure (ICP) and MAP. PRx was calculated as a moving, linear correlation between ICP and MAP. Impaired CAR was defined as PRx ≥ 0.3. MAPopt was calculated using a multi-window weighted algorithm. The burdens of MAP < 5 mmHg below MAPopt (MAPopt-5) and > 5 mmHg above MAPopt (MAPopt + 5) were calculated by integrating the area between MAP and MAPopt-5 or MAPopt + 5 curves, respectively. Univariate logistic regression tested the association between burden of MAP < MAPopt-5 and outcome. RESULTS Twenty-two patients were analyzed. Thirteen (59%) patients died before hospital discharge. Time (median [IQR]) between ROSC and monitoring initiation was 16 [14, 21] hours and duration of monitoring was 35 [22, 48] hours; neither differed between survivors and non-survivors. Median MAPopt was 89 [85, 97] mmHg and did not differ between survivors and non-survivors (89 [83, 94] vs. 91 [85, 105] mmHg, p = 0.64). Burden of MAP < MAPopt-5 was greater for non-survivors compared to survivors (OR 3.6 [95% CI 1.2-15.6]). Range of intact CAR (upper-lower limit) was narrower for non-survivors when compared to survivors (5 [0, 22] vs. 24 [7, 36] mmHg, p = 0.03). CONCLUSION A greater burden of MAP below PRx-derived MAPopt-5 was associated with mortality after cardiac arrest. Non-survivors had a narrower range of intact CAR than survivors.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States.
| | | | | | - Robert Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Benjamin S Abella
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, United States
| | - Ramani Balu
- Department of Emergency Medicine, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States
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27
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Moss L, Corsar D, Shaw M, Piper I, Hawthorne C. Demystifying the Black Box: The Importance of Interpretability of Predictive Models in Neurocritical Care. Neurocrit Care 2022; 37:185-191. [PMID: 35523917 PMCID: PMC9343258 DOI: 10.1007/s12028-022-01504-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/29/2022] [Indexed: 11/16/2022]
Abstract
Neurocritical care patients are a complex patient population, and to aid clinical decision-making, many models and scoring systems have previously been developed. More recently, techniques from the field of machine learning have been applied to neurocritical care patient data to develop models with high levels of predictive accuracy. However, although these recent models appear clinically promising, their interpretability has often not been considered and they tend to be black box models, making it extremely difficult to understand how the model came to its conclusion. Interpretable machine learning methods have the potential to provide the means to overcome some of these issues but are largely unexplored within the neurocritical care domain. This article examines existing models used in neurocritical care from the perspective of interpretability. Further, the use of interpretable machine learning will be explored, in particular the potential benefits and drawbacks that the techniques may have when applied to neurocritical care data. Finding a solution to the lack of model explanation, transparency, and accountability is important because these issues have the potential to contribute to model trust and clinical acceptance, and, increasingly, regulation is stipulating a right to explanation for decisions made by models and algorithms. To ensure that the prospective gains from sophisticated predictive models to neurocritical care provision can be realized, it is imperative that interpretability of these models is fully considered.
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Affiliation(s)
- Laura Moss
- Department of Clinical Physics & Bioengineering, NHS Greater Glasgow and Clyde, Room 2.41, Level 2, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK. .,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
| | - David Corsar
- School of Computing, Robert Gordon University, Aberdeen, UK
| | - Martin Shaw
- Department of Clinical Physics & Bioengineering, NHS Greater Glasgow and Clyde, Room 2.41, Level 2, New Lister Building, Glasgow Royal Infirmary, 10-16 Alexandra Parade, Glasgow, G31 2ER, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Ian Piper
- Usher Institute of Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Hawthorne
- Department of Neuroanaesthesia, Institute of Neurological Sciences, NHS Greater Glasgow and Clyde, Glasgow, UK
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Evaluation and Application of Ultra-Low-Resolution Pressure Reactivity Index in Moderate or Severe Traumatic Brain Injury. J Neurosurg Anesthesiol 2022. [DOI: 10.1097/ana.0000000000000847 10.1097/ana.0000000000000847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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29
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Casault C, Couillard P, Kromm J, Rosenthal E, Kramer A, Brindley P. Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners. J Intensive Care Soc 2022; 23:191-202. [PMID: 35615230 PMCID: PMC9125434 DOI: 10.1177/1751143720980273] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Traumatic brain injury (TBI) is common and potentially devastating. Traditional examination-based patient monitoring following TBI may be inadequate for frontline clinicians to reduce secondary brain injury through individualized therapy. Multimodal neurologic monitoring (MMM) offers great potential for detecting early injury and improving outcomes. By assessing cerebral oxygenation, autoregulation and metabolism, clinicians may be able to understand neurophysiology during acute brain injury, and offer therapies better suited to each patient and each stage of injury. Hence, we offer this primer on brain tissue oxygen monitoring, pressure reactivity index monitoring and cerebral microdialysis. This narrative review serves as an introductory guide to the latest clinically-relevant evidence regarding key neuromonitoring techniques.
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Affiliation(s)
- Colin Casault
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
| | - Philippe Couillard
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Julie Kromm
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Eric Rosenthal
- Department of Critical Care
Medicine, University of Alberta, Edmonton, Canada
| | - Andreas Kramer
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Peter Brindley
- Department of Neurology, Harvard
University, Boston, MA, USA
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30
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Bernard F, Barsan W, Diaz-Arrastia R, Merck LH, Yeatts S, Shutter LA. Brain Oxygen Optimization in Severe Traumatic Brain Injury (BOOST-3): a multicentre, randomised, blinded-endpoint, comparative effectiveness study of brain tissue oxygen and intracranial pressure monitoring versus intracranial pressure alone. BMJ Open 2022; 12:e060188. [PMID: 35273066 PMCID: PMC8915289 DOI: 10.1136/bmjopen-2021-060188] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/02/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Management of traumatic brain injury (TBI) includes invasive monitoring to prevent secondary brain injuries. Intracranial pressure (ICP) monitor is the main measurement used to that intent but cerebral hypoxia can occur despite normal ICP. This study will assess whether the addition of a brain tissue oxygenation (PbtO2) monitor prevents more secondary injuries that will translate into improved functional outcome. METHODS AND ANALYSIS Multicentre, randomised, blinded-endpoint comparative effectiveness study enrolling 1094 patients with severe TBI monitored with both ICP and PbtO2. Patients will be randomised to medical management guided by ICP alone (treating team blinded to PbtO2 values) or both ICP and PbtO2. Management is protocolised according to international guidelines in a tiered approach fashion to maintain ICP <22 mm Hg and PbtO2 >20 mm Hg. ICP and PbtO2 will be continuously recorded for a minimum of 5 days. The primary outcome measure is the Glasgow Outcome Scale-Extended performed at 180 (±30) days by a blinded central examiner. Favourable outcome is defined according to a sliding dichotomy where the definition of favourable outcome varies according to baseline severity. Severity will be defined according to the probability of poor outcome predicted by the IMPACT core model. A large battery of secondary outcomes including granular neuropsychological and quality of life measures will be performed. ETHICS AND DISSEMINATION This has been approved by Advarra Ethics Committee (Pro00030585). Results will be presented at scientific meetings and published in peer-reviewed publications. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03754114).
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Affiliation(s)
- Francis Bernard
- Critical Care, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
- Department of Medicine, Université de Montreal, Montreal, Québec, Canada
| | - William Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ramon Diaz-Arrastia
- Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lisa H Merck
- Emergency Medicine and Neurology, Neurocritical Care, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sharon Yeatts
- Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lori A Shutter
- Critical Care Medicine, Neurology, & Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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31
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Continuous Determination of the Optimal Bispectral Index Value Based on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A Retrospective Observational Cohort Study of a Novel Individualized Sedation Target. Crit Care Explor 2022; 4:e0656. [PMID: 35265854 PMCID: PMC8901214 DOI: 10.1097/cce.0000000000000656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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32
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Schweingruber N, Mader M, Wiehe A, Röder F, Göttsche J, Kluge S, Westphal M, Czorlich P, Gerloff C. A recurrent machine learning model predicts intracranial hypertension in neurointensive care patients. Brain 2022; 145:2910-2919. [PMID: 35139181 PMCID: PMC9486888 DOI: 10.1093/brain/awab453] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/24/2021] [Accepted: 11/19/2021] [Indexed: 11/14/2022] Open
Abstract
The evolution of intracranial pressure (ICP) of critically ill patients admitted to a neurointensive care unit (ICU) is difficult to predict. Besides the underlying disease and compromised intracranial space, ICP is affected by a multitude of factors, many of which are monitored on the ICU, but the complexity of the resulting patterns limits their clinical use. This paves the way for new machine learning (ML) techniques to assist clinical management of patients undergoing invasive ICP monitoring independent of the underlying disease. An institutional cohort (ICP-ICU) of patients with invasive ICP monitoring (n = 1346) was used to train recurrent ML models to predict the occurrence of ICP increases of ≥ 22mmHg over a long (> 2 hours) time period in the upcoming hours. External validation was performed on patients undergoing invasive ICP measurement in two publicly available datasets (Medical Information Mart for Intensive Care (MIMIC, n = 998) and eICU Collaborative Research Database (eICU, n = 1634)). Different distances (1h-24 h) between prediction time point and upcoming critical phase were evaluated, demonstrating a decrease in performance but still robust AUC-ROC with larger distances (24 h AUC-ROC: ICP-ICU 0.826 ± 0.0071, MIMIC 0.836 ± 0.0063, eICU 0.779 ± 0.0046, 1 h AUC-ROC: ICP-ICU 0.982 ± 0.0008, MIMIC 0.965 ± 0.0010, eICU 0.941 ± 0.0025). The model operates on sparse hourly data and is stable in handling variable input lengths and missingness through its nature of recurrence and internal memory. Calculation of gradient-based feature importance revealed individual underlying decisions for our Long Short Time Memory (LSTM) based model and thereby provided improved clinical interpretability. Recurrent ML models have the potential to be an effective tool for the prediction of ICP increases with high translational potential.
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Affiliation(s)
- Nils Schweingruber
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany
| | - Marius Mader
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University
| | - Anton Wiehe
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany.,Department of Informatics, University of Hamburg, Hamburg, 22527, Germany
| | - Frank Röder
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany.,Department of Informatics, University of Hamburg, Hamburg, 22527, Germany
| | - Jennifer Göttsche
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Patrick Czorlich
- Department of Neurosurgery, University Medical Centre Hamburg-Eppendorf, Hamburg 20246, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, 20246, Germany
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33
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Deviations from NIRS-derived optimal blood pressure are associated with worse outcomes after pediatric cardiac arrest. Resuscitation 2021; 168:110-118. [PMID: 34600027 DOI: 10.1016/j.resuscitation.2021.09.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
AIM Evaluate cerebrovascular autoregulation (CAR) using near-infrared spectroscopy (NIRS) after pediatric cardiac arrest and determine if deviations from CAR-derived optimal mean arterial pressure (MAPopt) are associated with outcomes. METHODS CAR was quantified by a moving, linear correlation between time-synchronized mean arterial pressure (MAP) and regional cerebral oxygenation, called cerebral oximetry index (COx). MAPopt was calculated using a multi-window weighted algorithm. We calculated burden (magnitude and duration) of MAP less than 5 mmHg below MAPopt (MAPopt - 5), as the area between MAP and MAPopt - 5 curves using numerical integration and normalized as percentage of monitoring duration. Unfavorable outcome was defined as death or pediatric cerebral performance category (PCPC) at hospital discharge ≥3 with ≥1 change from baseline. Univariate logistic regression tested association between burden of MAP less than MAPopt - 5 and outcome. RESULTS Thirty-four children (median age 2.9 [IQR 1.5,13.4] years) were evaluated. Median COx in the first 24 h post-cardiac arrest was 0.06 [0,0.20]; patients spent 27% [19,43] of monitored time with COx ≥ 0.3. Patients with an unfavorable outcome (n = 24) had a greater difference between MAP and MAPopt - 5 (13 [11,19] vs. 9 [8,10] mmHg, p = 0.01) and spent more time with MAP below MAPopt - 5 (38% [26,61] vs. 24% [14,28], p = 0.03). Patients with unfavorable outcome had a higher burden of MAP less than MAPopt - 5 than patients with favorable outcome in the first 24 h post-arrest (187 [107,316] vs. 62 [43,102] mmHg × Min/Hr; OR 4.93 [95% CI 1.16-51.78]). CONCLUSIONS Greater burden of MAP below NIRS-derived MAPopt - 5 during the first 24 h after cardiac arrest was associated with unfavorable outcomes.
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Joram N, Beqiri E, Pezzato S, Andrea M, Robba C, Liet JM, Chenouard A, Bourgoin P, Czosnyka M, Léger PL, Smielewski P. Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO. Neurocrit Care 2021; 35:480-490. [PMID: 33686559 DOI: 10.1007/s12028-021-01201-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) impairment is associated with neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Severe variations of arterial CO2 (PaCO2) and O2 (PaO2) tension after ECMO onset are common and associate with mortality and poor neurological outcome. The impact of gas exchange on CA among critically ill patients is poorly studied. METHODS Retrospective analysis of data collected prospectively from 30 children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France. A correlation coefficient between the variations of regional cerebral oxygen saturation (rSO2) and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). Cox-MAP plots were investigated allowing determining lower limit of autoregulation (LLA) and upper limit of autoregulation (ULA) limits of autoregulation. Age-based normal blood pressure was used to adjust the MAP, LLA, and ULA data from each patient and then reported as percentage (nMAP, nLLA, and nULA, respectively). RSO2, COx, nMAP, nLLA, and nULA values were averaged over one hour before each arterial blood gas (ABG) sample during ECMO run. RESULTS Thirty children (median age 4.8 months [Interquartile range (IQR) 0.7-39.1], median weight 5 kg [IQR 4-15]) experiencing 31 ECMO runs were included in the study. Three hundred and ninety ABGs were analyzed. The highest values of COx were observed on day 1 (D1) of ECMO. The relationship between COx and PaCO2 was nonlinear, but COx values tended to be lower in case of hypercapnia compared to normocapnia. During the whole ECMO run, a weak but significant correlation between PaCO2 and nULA was observed (R = 0.432, p = 0.02). On D1 of ECMO, this correlation was stronger (R = 0.85, p = 0.03) and a positive correlation between nLLA and PaCO2 was also found (R = 0.726, p < 0.001). A very weak negative correlation between PaO2 and nULA was observed within the whole ECMO run and on D1 of ECMO (R = -0.07 p = 0.04 and R = -0.135 p = <0.001, respectively). The difference between nULA and nLLA representing the span of the autoregulation plateau was positively correlated with PaCO2 and negatively correlated with PaO2 (R = 0.224, p = 0.01 and R = -0.051, p = 0.004, respectively). CONCLUSIONS We observed a complex relationship between PaCO2 and CA, influenced by the level of blood pressure. Hypercapnia seems to be globally protective in normotensive or hypertensive condition, while, in case of very low MAP, hypercapnia may disturb CA as it increases LLA. These data add additional arguments for very cautiously lower PaCO2, especially after ECMO start.
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Affiliation(s)
- Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France. .,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France. .,INSERM U955-ENVA, University Paris 12, Paris, France.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Stefano Pezzato
- Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Moscatelli Andrea
- Pediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Chiara Robba
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC) 1413, University Hospital of Nantes, Nantes, France
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Pierre-Louis Léger
- INSERM U955-ENVA, University Paris 12, Paris, France.,Pediatric Intensive Care Unit, Trousseau University Hospital, Paris, France
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Trans-Ocular Brain Impedance Indices Predict Pressure Reactivity Index Changes in a Porcine Model of Hypotension and Cerebral Autoregulation Perturbation. Neurocrit Care 2021; 36:139-147. [PMID: 34244920 DOI: 10.1007/s12028-021-01272-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cerebrovascular autoregulation (CA) is a protective mechanism that enables the cerebral vasculature to automodulate tone in response to changes in cerebral perfusion pressure to ensure constant levels of cerebral blood flow (CBF) and oxygen delivery. CA can be impaired after neurological injury and contributes to secondary brain injury. In this study, we report novel impedance indices using trans-ocular brain impedance (TOBI) during controlled systemic hemorrhage and hypotension to assess CA in comparison with pressure reactivity index (PRx). METHODS Yorkshire swine were instrumented to record intracranial pressure (ICP), mean arterial pressure (MAP), and CBF. TOBI was recorded using electrocardiographic electrodes placed on the closed eyelids. Impedance changes (dz) were recorded in response to introducing an alternating current (0.4 mA) through the electrodes. MAP, ICP, and CBF were also measured. Animals were subjected to a controlled hemorrhage to remove 30-40% of each animal's total blood volume over 25-35 min. Hemorrhage was titrated to reach an MAP of approximately 35 mm Hg and end-tidal carbon dioxide above 28 mm Hg. PRx was calculated as a moving Pearson correlation between MAP and ICP. TOBI indices were calculated as the amplitude of the respiratory-induced changes in dz. DZx was calculated as a moving Pearson correlation between dz and MAP. TOBI indices (dz and DZx) were compared with hemodynamic indicators and PRx. RESULTS dz was shown to be highly correlated with MAP, ICP, cerebral perfusion pressure, and CBF (r = - 0.823, - 0.723, - 0.813, and - 0.726), respectively (p < 0.0001). During hemorrhage, cerebral perfusion pressure and CBF had a mean percent decrease (standard deviation) from baseline of - 54.2% (12.5%) and - 28.3% (14.7%), respectively, whereas dz increased by 277% (268%). Receiver operator characteristics and precision-recall curves demonstrated high predictive performance of DZx when compared with PRx with an area under the curve above 0.82 and 0.89 for receiver operator characteristic and precision-recall curves, respectively, with high sensitivity and positive predictive power. CONCLUSIONS TOBI indices appear to track changes in PRx and hemodynamics that affect CA during hemorrhage-induced hypotension. TOBI may offer a suitable, less invasive surrogate to PRx for monitoring and assessing CA.
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Optimal Cerebral Perfusion Pressure Assessed with a Multi-Window Weighted Approach Adapted for Prospective Use: A Validation Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:181-185. [PMID: 33839842 DOI: 10.1007/978-3-030-59436-7_36] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pressure reactivity index (PRx)-cerebral perfusion pressure (CPP) relationships over a given time period can be used to detect a value of CPP at which PRx shows the best autoregulation (optimal CPP, or CPPopt). Algorithms for continuous assessment of CPPopt in traumatic brain injury (TBI) patients reached the desired high yield with a multi-window approach (CPPopt_MA). However, the calculations were tested on retrospective manually cleaned datasets. Moreover, CPPopt false-positive values can be generated from non-physiological variations of intracranial pressure (ICP) and arterial blood pressure (ABP). Therefore, the algorithm robustness was improved, making it suitable for prospective bedside application (COGiTATE trial). OBJECTIVE To validate the CPPopt revised algorithm in a large single-centre retrospective cohort of TBI patients. METHODS 840 TBI patients were included. CPPopt yield, stability and ability to discriminate outcome groups were compared to CPPopt_MA and the Brain Trauma Foundation (BTF) guideline reference. RESULTS CPPopt yield was lower than CPPopt_MA yield (85% and 90%, p < 0.001), but, importantly, with increased stability (p < 0.0001). The ∆(CPP-CPPopt) could distinguish the mortality and survival outcome (t = -6.7, p < 0.0001) with a statistical significance higher than the ∆CPP calculated with the guideline reference (CPP-60) (t = -4.5, p < 0.0001). CONCLUSION This study validates, on a large cohort of patients, the new algorithm proposed for prospective use of CPPopt as a CPP target at bedside.
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Tas J, Beqiri E, van Kaam CR, Ercole A, Bellen G, Bruyninckx D, Cabeleira M, Czosnyka M, Depreitere B, Donnelly J, Fedriga M, Hutchinson PJ, Menon D, Meyfroidt G, Liberti A, Outtrim JG, Robba C, Hoedemaekers CWE, Smielewski P, Aries MJ. An Update on the COGiTATE Phase II Study: Feasibility and Safety of Targeting an Optimal Cerebral Perfusion Pressure as a Patient-Tailored Therapy in Severe Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:143-147. [PMID: 33839835 DOI: 10.1007/978-3-030-59436-7_29] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Monitoring of cerebral autoregulation (CA) in patients with a traumatic brain injury (TBI) can provide an individual 'optimal' cerebral perfusion pressure (CPP) target (CPPopt) at which CA is best preserved. This potentially offers an individualized precision medicine approach. Retrospective data suggest that deviation of CPP from CPPopt is associated with poor outcomes. We are prospectively assessing the feasibility and safety of this approach in the COGiTATE [CPPopt Guided Therapy: Assessment of Target Effectiveness] study. Its primary objective is to demonstrate the feasibility of individualizing CPP at CPPopt in TBI patients. The secondary objectives are to investigate the safety and physiological effects of this strategy. METHODS The COGiTATE study has included patients in four European hospitals in Cambridge, Leuven, Nijmegen, and Maastricht (coordinating centre). Patients with severe TBI requiring intracranial pressure (ICP)-directed therapy are allocated into one of two groups. In the intervention group, CPPopt is calculated using a published (modified) algorithm. In the control group, the CPP target recommended in the Brain Trauma Foundation guidelines (CPP 60-70 mmHg) is used. RESULTS Patient recruitment started in February 2018 and will continue until 60 patients have been studied. Fifty-one patients (85% of the intended total) have been recruited in October 2019. The first results are expected early 2021. CONCLUSION This prospective evaluation of the feasibility, safety and physiological implications of autoregulation-guided CPP management is providing evidence that will be useful in the design of a future phase III study in severe TBI patients.
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - C R van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ari Ercole
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Gert Bellen
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - D Bruyninckx
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marta Fedriga
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - D Menon
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Cellular and Molecular Medicine, Catholic University Leuven, University Hospital, Leuven, Belgium
| | - Annalisa Liberti
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J G Outtrim
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - C Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - C W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marcel J Aries
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
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Liu X, Akiyoshi K, Nakano M, Brady K, Bush B, Nadkarni R, Venkataraman A, Koehler RC, Lee JK, Hogue CW, Czosnyka M, Smielewski P, Brown CH. Determining Thresholds for Three Indices of Autoregulation to Identify the Lower Limit of Autoregulation During Cardiac Surgery. Crit Care Med 2021; 49:650-660. [PMID: 33278074 PMCID: PMC7979429 DOI: 10.1097/ccm.0000000000004737] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Monitoring cerebral autoregulation may help identify the lower limit of autoregulation in individual patients. Mean arterial blood pressure below lower limit of autoregulation appears to be a risk factor for postoperative acute kidney injury. Cerebral autoregulation can be monitored in real time using correlation approaches. However, the precise thresholds for different cerebral autoregulation indexes that identify the lower limit of autoregulation are unknown. We identified thresholds for intact autoregulation in patients during cardiopulmonary bypass surgery and examined the relevance of these thresholds to postoperative acute kidney injury. DESIGN A single-center retrospective analysis. SETTING Tertiary academic medical center. PATIENTS Data from 59 patients was used to determine precise cerebral autoregulation thresholds for identification of the lower limit of autoregulation. These thresholds were validated in a larger cohort of 226 patients. METHODS AND MAIN RESULTS Invasive mean arterial blood pressure, cerebral blood flow velocities, regional cortical oxygen saturation, and total hemoglobin were recorded simultaneously. Three cerebral autoregulation indices were calculated, including mean flow index, cerebral oximetry index, and hemoglobin volume index. Cerebral autoregulation curves for the three indices were plotted, and thresholds for each index were used to generate threshold- and index-specific lower limit of autoregulations. A reference lower limit of autoregulation could be identified in 59 patients by plotting cerebral blood flow velocity against mean arterial blood pressure to generate gold-standard Lassen curves. The lower limit of autoregulations defined at each threshold were compared with the gold-standard lower limit of autoregulation determined from Lassen curves. The results identified the following thresholds: mean flow index (0.45), cerebral oximetry index (0.35), and hemoglobin volume index (0.3). We then calculated the product of magnitude and duration of mean arterial blood pressure less than lower limit of autoregulation in a larger cohort of 226 patients. When using the lower limit of autoregulations identified by the optimal thresholds above, mean arterial blood pressure less than lower limit of autoregulation was greater in patients with acute kidney injury than in those without acute kidney injury. CONCLUSIONS This study identified thresholds of intact and impaired cerebral autoregulation for three indices and showed that mean arterial blood pressure below lower limit of autoregulation is a risk factor for acute kidney injury after cardiac surgery.
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Affiliation(s)
- Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kei Akiyoshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mitsunori Nakano
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Saitama Medical Center, Jichi Medical University, Saitama, Japan 330-8503
| | - Ken Brady
- Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Anesthesiology, Chicago, Illinois, USA
| | - Brian Bush
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rohan Nadkarni
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Archana Venkataraman
- Department of Electrical and Computer Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles W. Hogue
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgey, Cambridge University Hospitals, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgey, Cambridge University Hospitals, University of Cambridge, Cambridge, UK
| | - Charles H. Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Fan BB, Sun XC, Huang ZJ, Yang XM, Guo ZD, He ZH. Hypoperfusion assessed by pressure reactivity index is associated with delayed cerebral ischemia after subarachnoid hemorrhage: an observational study. Chin Neurosurg J 2021; 7:16. [PMID: 33648581 PMCID: PMC7923615 DOI: 10.1186/s41016-021-00231-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Dysfunction of cerebral autoregulation is one of the pathophysiological mechanisms that causes delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). Pressure reactivity index (PRx) have been confirmed to reflect the level of cerebral autoregulation and used to derive optimal cerebral perfusion pressure (CPPopt). The goal of this study is to explore the associations between autoregulation, CPPopt, PRx, and DCI. Methods Continuous intracranial pressure (ICP), arterial blood pressure (ABP), and cerebral perfusion pressure (CPP) signals acquired from 61 aSAH patients were retrospectively analyzed. PRx was calculated and collected by Pneumatic computer system. The CPP at the lowest PRx was determined as the CPPopt. The duration of a hypoperfusion event (dHP) was defined as the cumulative time that the PRx was > 0.3 and the CPP was <CPPopt. The duration of CPP more than 10 mmHg below CPPopt (ΔCPPopt < − 10 mmHg) was also used to assess hypoperfusion. The percent of the time of hypoperfusion by dHP and ΔCPPopt < − 10 mmHg (%dHP and %ΔCPPopt) were compared between DCI group and control group, utilizing univariate and multivariable logistic regression. It was the clinical prognosis at 3 months after hemorrhage that was assessed with the modified Rankin Scale, and logistic regression and ROC analysis were used for predictive power for unfavorable outcomes (mRs 3–5). Results Data from 52 patients were included in the final analysis of 61 patients. The mean %dHP in DCI was 29.23% and 10.66% in control. The mean %ΔCPPopt < − 10 mmHg was 22.28%, and 5.90% in control. The %dHP (p < 0.001) and the %ΔCPPopt < − 10mmHg (p < 0.001) was significantly longer in the DCI group. In multivariate logistic regression model, %ΔCPPopt <− 10 mmHg (p < 0.001) and %dHP (p < 0.001) were independent risk factor for predicting DCI, and %ΔCPPopt <− 10 mmHg (p = 0.010) and %dHP (p = 0.026) were independent risk factor for predicting unfavorable outcomes. Conclusions The increase of duration of hypoperfusion events and duration of CPP below CPPopt over 10 mmHg, evaluated as time of lowered CPP, is highly indicative of DCI and unfavorable outcomes.
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Affiliation(s)
- Bin Bin Fan
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Chuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Zhi Jian Huang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao Min Yang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zong Duo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhao Hui He
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Svedung Wettervik TM, Lewén A, Enblad P. Fine Tuning of Traumatic Brain Injury Management in Neurointensive Care-Indicative Observations and Future Perspectives. Front Neurol 2021; 12:638132. [PMID: 33716941 PMCID: PMC7943830 DOI: 10.3389/fneur.2021.638132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 01/20/2021] [Indexed: 01/01/2023] Open
Abstract
Neurointensive care (NIC) has contributed to great improvements in clinical outcomes for patients with severe traumatic brain injury (TBI) by preventing, detecting, and treating secondary insults and thereby reducing secondary brain injury. Traditional NIC management has mainly focused on generally applicable escalated treatment protocols to avoid high intracranial pressure (ICP) and to keep the cerebral perfusion pressure (CPP) at sufficiently high levels. However, TBI is a very heterogeneous disease regarding the type of injury, age, comorbidity, secondary injury mechanisms, etc. In recent years, the introduction of multimodality monitoring, including, e.g., pressure autoregulation, brain tissue oxygenation, and cerebral energy metabolism, in addition to ICP and CPP, has increased the understanding of the complex pathophysiology and the physiological effects of treatments in this condition. In this article, we will present some potential future approaches for more individualized patient management and fine-tuning of NIC, taking advantage of multimodal monitoring to further improve outcome after severe TBI.
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Affiliation(s)
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Challenges and Opportunities in Multimodal Monitoring and Data Analytics in Traumatic Brain Injury. Curr Neurol Neurosci Rep 2021; 21:6. [PMID: 33527217 PMCID: PMC7850903 DOI: 10.1007/s11910-021-01098-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. RECENT FINDINGS Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
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Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, Meyfroidt G. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians. Neurocrit Care 2021; 34:731-738. [PMID: 33495910 PMCID: PMC8179892 DOI: 10.1007/s12028-020-01185-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. AIM To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. METHODS A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. RESULTS Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. CONCLUSION The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
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Affiliation(s)
- B Depreitere
- Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - G Citerio
- Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - M Smith
- Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - P David Adelson
- Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - M J Aries
- Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands
| | - T P Bleck
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France
| | - R Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - V De Sloovere
- Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - M Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - J Dureanteau
- Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France
| | - A Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - G Hawryluk
- Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - C Hawthorne
- Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK
| | - R Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S P Klein
- Neurosurgery, University Hospital Brussels, Brussels, Belgium
| | - J O Neumann
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Robba
- Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - L Steiner
- Anesthesiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - N Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - S Wolf
- Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany
| | - F A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - G Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Kommer M, Canty M, Campbell E, Sangra M, Amato-Watkins A, Young S, Hawthorne C, Moss L, Piper I, Shaw M, O'Kane R. Use of Direct Intracranial Pressure and Brain Tissue Oxygen Monitoring in Perioperative Management of Patients with Moyamoya Disease. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:115-117. [PMID: 33839830 DOI: 10.1007/978-3-030-59436-7_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Intracranial pressure monitoring and brain tissue oxygen monitoring are commonly used in head injury for goal-directed therapies, but there may be more indications for its use. Moyamoya disease involves progressive stenosis of the arterial circulation and formation of collateral vessels that are at risk of hemorrhage. The risk of ischemic events during revascularization surgery and postoperatively is high. Impaired cerebral autoregulation may be one of the factors that are implicated. We present our experience with monitoring of cerebral oxygenation and autoregulation in the pathological hemisphere during the perioperative period in four patients with moyamoya disease.
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Affiliation(s)
- Maya Kommer
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK.
- Royal Hospital for Children, Glasgow, UK.
| | - Michael Canty
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emer Campbell
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
| | | | - Anthony Amato-Watkins
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
| | - Simon Young
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
| | - Christopher Hawthorne
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Laura Moss
- NHS Greater Glasgow Clyde, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Ian Piper
- Usher Institute of Population Health and Informatics, University of Edinburgh, Edinburgh, UK
| | - Martin Shaw
- NHS Greater Glasgow Clyde, Glasgow, UK
- University of Glasgow, Glasgow, UK
| | - Roddy O'Kane
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
- Royal Hospital for Children, Glasgow, UK
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Promlek K, Currey J, Damkliang J, Considine J. Evidence-practice gaps in initial neuro-protective nursing care: A mixed methods study of Thai patients with moderate or severe traumatic brain injury. Int J Nurs Pract 2020; 27:e12899. [PMID: 33300208 DOI: 10.1111/ijn.12899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 06/10/2020] [Accepted: 10/26/2020] [Indexed: 11/27/2022]
Abstract
AIMS This paper aims to identify the frequency and nature of evidence-practice gaps in the initial neuro-protective nursing care of patients with moderate or severe traumatic brain injury provided by Thai trauma nurses. BACKGROUND Little is known about how Thai trauma nurses use evidence-based practice when providing initial neuro-protective nursing care to patients with moderate or severe traumatic brain injury. DESIGN A mixed methods design was used to conduct this study. METHODS Data were collected from January to March 2017 using observations and audits of the clinical care of 22 patients by 35 nurses during the first 4 h of admission to trauma ward. The study site was a regional hospital in Southern Thailand. RESULTS The major evidence-practice gaps identified were related to oxygen and carbon dioxide monitoring and targets, mean arterial pressure and systolic blood pressure targets and management of increased intracranial pressure through patient positioning and pain and agitation management. CONCLUSION There were evidence-practice gaps in initial neuro-protective nursing care provided by Thai trauma nurses that need to be addressed to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury.
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Affiliation(s)
- Kesorn Promlek
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University Geelong, Geelong, Australia.,Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand
| | - Judy Currey
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University Geelong, Geelong, Australia
| | | | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University Geelong, Geelong, Australia.,Centre for Quality and Patient Safety Research-Eastern Health Partnership, Box Hill, Victoria, Australia
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Continuous Monitoring of Cerebral Autoregulation in Children Supported by Extracorporeal Membrane Oxygenation: A Pilot Study. Neurocrit Care 2020; 34:935-945. [PMID: 33029743 DOI: 10.1007/s12028-020-01111-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Cerebral autoregulation (CA) impairment may pose a risk factor for neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Our first objective was to investigate the feasibility of CA continuous monitoring during ECMO treatment and to describe its evolution over time. The second objective was to analyze the association between CA impairment and neurological outcome. DESIGN Observational prospective study. PATIENTS AND SETTING Twenty-nine children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France, and the PICU of the IRCCS Giannina Gaslini Institute in Genoa, Italy. MEASUREMENTS A correlation coefficient between the variations of regional cerebral oxygen saturation and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). A COx > 0.3 was considered as indicative of autoregulation impairment. COx-MAP plots were investigated allowing determining optimal MAP (MAPopt) and limits of autoregulation: lower (LLA) and upper (ULA). Neurological outcome was assessed by the onset of an acute neurological event (ANE) after ECMO start. RESULTS We included 29 children (median age 84 days, weight 4.8 kg). MAPopt, LLA, and ULA were detected in 90.8% (84.3-93.3) of monitoring time. Mean COx was significantly higher during day 1 of ECMO compared to day 2 [0.1 (0.02-0.15) vs. 0.01 (- 0.05 to 0.1), p = 0.002]. Twelve children experienced ANE (34.5%). The mean COx and the percentage of time spent with a COx > 0.3 were significantly higher among ANE+ compared to ANE- patients [0.09 (0.01-0.23) vs. 0.04 (- 0.02 to 0.06), p = 0.04 and 33.3% (24.8-62.1) vs. 20.8% (17.3-23.7) p = 0.001]. ANE+ patients spent significantly more time with MAP below LLA [17.2% (6.5-32.9) vs. 5.6% (3.6-9.9), p = 0.02] and above ULA [13% (5.3-38.4) vs. 4.2% (2.7-7.4), p = 0.004], respectively. CONCLUSION CA assessment is feasible in pediatric ECMO. The first 24 h following ECMO represents the most critical period regarding CA. Impaired autoregulation is significantly more severe among patients who experience ANE.
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Thelin EP, Raj R, Bellander BM, Nelson D, Piippo-Karjalainen A, Siironen J, Tanskanen P, Hawryluk G, Hasen M, Unger B, Zeiler FA. Comparison of high versus low frequency cerebral physiology for cerebrovascular reactivity assessment in traumatic brain injury: a multi-center pilot study. J Clin Monit Comput 2020; 34:971-994. [PMID: 31573056 PMCID: PMC7447671 DOI: 10.1007/s10877-019-00392-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/22/2019] [Indexed: 01/16/2023]
Abstract
Current accepted cerebrovascular reactivity indices suffer from the need of high frequency data capture and export for post-acquisition processing. The role for minute-by-minute data in cerebrovascular reactivity monitoring remains uncertain. The goal was to explore the statistical time-series relationships between intra-cranial pressure (ICP), mean arterial pressure (MAP) and pressure reactivity index (PRx) using both 10-s and minute data update frequency in TBI. Prospective data from 31 patients from 3 centers with moderate/severe TBI and high-frequency archived physiology were reviewed. Both 10-s by 10-s and minute-by-minute mean values were derived for ICP and MAP for each patient. Similarly, PRx was derived using 30 consecutive 10-s data points, updated every minute. While long-PRx (L-PRx) was derived via similar methodology using minute-by-minute data, with L-PRx derived using various window lengths (5, 10, 20, 30, 40, and 60 min; denoted L-PRx_5, etc.). Time-series autoregressive integrative moving average (ARIMA) and vector autoregressive integrative moving average (VARIMA) models were created to analyze the relationship of these parameters over time. ARIMA modelling, Granger causality testing and VARIMA impulse response function (IRF) plotting demonstrated that similar information is carried in minute mean ICP and MAP data, compared to 10-s mean slow-wave ICP and MAP data. Shorter window L-PRx variants, such as L-PRx_5, appear to have a similar ARIMA structure, have a linear association with PRx and display moderate-to-strong correlations (r ~ 0.700, p < 0.0001 for each patient). Thus, these particular L-PRx variants appear closest in nature to standard PRx. ICP and MAP derived via 10-s or minute based averaging display similar statistical time-series structure and co-variance patterns. PRx and L-PRx based on shorter windows also behave similarly over time. These results imply certain L-PRx variants may carry similar information to PRx in TBI.
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Affiliation(s)
- Eric P. Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Anna Piippo-Karjalainen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Tanskanen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Gregory Hawryluk
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Mohammed Hasen
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
- Department of Neurosurgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Bertram Unger
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A. Zeiler
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Comparison of Pressure Reactivity Index and Mean Velocity Index to Evaluate Cerebrovascular Reactivity During Induced Arterial Blood Pressure Variations in Severe Brain Injury. Neurocrit Care 2020; 34:974-982. [PMID: 33006033 DOI: 10.1007/s12028-020-01092-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To compare the assessment of cerebral autoregulation by cerebrovascular reactivity indices based on intracranial pressure (Pressure Reactivity Index, PRx) and on transcranial Doppler (Mean Velocity Index, Mx) during controlled variations of arterial blood pressure in severe brain injury. Primary outcome was the agreement between both cerebrovascular reactivity indices measured by the Bland-and-Altman method. Secondary outcomes were the association of cerebrovascular reactivity indices with arterial blood pressure variation, and the comparison of optimal cerebral perfusion pressures determined by both indices. METHODS All consecutive comatose (Glasgow Coma Scale < 8) patients from the surgical intensive care unit of Bicetre Hospital who had an acute brain injury on computerized tomography and needed vasopressor support were prospectively included. Step-by-step arterial pressure variations using vasopressors were performed to compare PRx and Mx and to calculate optimal cerebral perfusion pressure (CPPopt). MEASUREMENTS AND MAIN RESULTS 15 patients were included. Mean difference between both indices measured by Bland-and-Altman plot was - 0.07 (IC 95% [- 1.02 to 0.87]). Mx was significantly associated with arterial pressure variation (one-way ANOVA test, p = 0.007), whereas PRx was not (p = 0.44). Optimal cerebral perfusion pressure calculated with PRx and Mx was respectively 11 and 15mmHg higher than the mean perfusion pressure prescribed. Optimal cerebral perfusion pressure calculation was possible in all cases. CONCLUSIONS Cerebral vasoreactivity indices calculated with intracranial pressure or transcranial Doppler show only moderate agreement. Both indices nonetheless suggest substantially higher optimal cerebral perfusion pressure than those currently provided by international guidelines.
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Cerebral Hemodynamic Profile in Ischemic and Hemorrhagic Brain Injury Acquired During Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:879-885. [PMID: 32569240 DOI: 10.1097/pcc.0000000000002438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the cerebral hemodynamic profiles associated with ischemic and hemorrhagic brain injury during neonatal and pediatric extracorporeal membrane oxygenation. DESIGN A retrospective cohort study. SETTING Tertiary PICU. PATIENTS Forty-seven neonatal and pediatric patients (0-15 yr of age) placed on extracorporeal membrane oxygenation from January 2014 to December 2018. MEASUREMENTS AND MAIN RESULTS Continuous monitoring of mean arterial pressure and cerebral tissue oxygen saturation was conducted through entire extracorporeal membrane oxygenation run. Wavelet analysis was performed to assess changes in cerebral autoregulation and to derive pressure-dependent autoregulation curves based on the mean arterial pressure and cerebral tissue oxygen saturation data. Patients were classified into three brain injury groups: no-injury, ischemic injury, and hemorrhagic injury based on neuroimaging results. No-injury patients (n = 23) had minimal variability in the autoregulation curve over a broad range of blood pressure. Ischemic injury (n = 16) was more common than hemorrhagic injury (n = 8), and the former was associated with increased mortality and morbidity. Ischemic group showed significant abnormalities in cerebral autoregulation in the lower blood pressure range, suggesting pressure-dependent cerebral perfusion. Hemorrhagic group had highest average blood pressure as well as the lowest cerebral tissue oxygenation saturation, suggesting elevated cerebral vascular resistance. Mean heparin dose during extracorporeal membrane oxygenation was lower in both ischemic and hemorrhagic groups compared with the no-injury group. CONCLUSIONS This study outlines distinct differences in underlying cerebral hemodynamics associated with ischemic and hemorrhagic brain injury acquired during extracorporeal membrane oxygenation. Real-time monitoring of cerebral hemodynamics in patients acquiring brain injury during extracorporeal membrane oxygenation can help optimize their management.
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Near-Infrared Spectroscopy to Assess Cerebral Autoregulation and Optimal Mean Arterial Pressure in Patients With Hypoxic-Ischemic Brain Injury: A Prospective Multicenter Feasibility Study. Crit Care Explor 2020; 2:e0217. [PMID: 33063026 PMCID: PMC7523861 DOI: 10.1097/cce.0000000000000217] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. We provide preliminary multicenter data to suggest that recruitment and collection of physiologic data necessary to quantify cerebral autoregulation and individualized blood pressure targets are feasible in postcardiac arrest patients. We evaluated the feasibility of a multicenter protocol to enroll patients across centers, as well as collect continuous recording (≥ 80% of monitoring time) of regional cerebral oxygenation and mean arterial pressure, which is required to quantify cerebral autoregulation, using the cerebral oximetry index, and individualized optimal mean arterial pressure thresholds. Additionally, we conducted an exploratory analysis to assess if an increased percentage of monitoring time where mean arterial pressure was greater than or equal to 5 mm Hg below optimal mean arterial pressure, percentage of monitoring time with dysfunctional cerebral autoregulation (i.e., cerebral oximetry index ≥ 0.3), and time to return of spontaneous circulation were associated with an unfavorable neurologic outcome (i.e., 6-mo Cerebral Performance Category score ≥ 3).
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50
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Impaired cerebral blood flow regulation in chronic traumatic brain injury. Brain Res 2020; 1743:146924. [DOI: 10.1016/j.brainres.2020.146924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 01/26/2023]
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