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Sardesai N, Hibberd O, Price J, Ercole A, Barnard EBG. Agreement between arterial and end-tidal carbon dioxide in adult patients admitted with serious traumatic brain injury. PLoS One 2024; 19:e0297113. [PMID: 38306331 PMCID: PMC10836696 DOI: 10.1371/journal.pone.0297113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/27/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Low-normal levels of arterial carbon dioxide (PaCO2) are recommended in the acute phase of traumatic brain injury (TBI) to optimize oxygen and CO2 tension, and to maintain cerebral perfusion. End-tidal CO2 (ETCO2) may be used as a surrogate for PaCO2 when arterial sampling is less readily available. ETCO2 may not be an adequate proxy to guide ventilation and the effects on concomitant injury, time, and the impact of ventilatory strategies on the PaCO2-ETCO2 gradient are not well understood. The primary objective of this study was to describe the correlation and agreement between PaCO2 and ETCO2 in intubated adult trauma patients with TBI. METHODS This study was a retrospective analysis of prospectively-collected data of intubated adult major trauma patients with serious TBI, admitted to the East of England regional major trauma centre; 2015-2019. Linear regression and Welch's test were performed on each cohort to assess correlation between paired PaCO2 and ETCO2 at 24-hour epochs for 120 hours after admission. Bland-Altman plots were constructed at 24-hour epochs to assess the PaCO2-ETCO2 agreement. RESULTS 695 patients were included, with 3812 paired PaCO2 and ETCO2 data points. The median PaCO2-ETCO2 gradient on admission was 0.8 [0.4-1.4] kPa, Bland Altman Bias of 0.96, upper (+2.93) and lower (-1.00), and correlation R2 0.149. The gradient was significantly greater in patients with TBI plus concomitant injury, compared to those with isolated TBI (0.9 [0.4-1.5] kPa vs. 0.7 [0.3-1.1] kPa, p<0.05). Across all groups the gradient reduced over time. Patients who died within 30 days had a larger gradient on admission compared to those who survived; 1.2 [0.7-1.9] kPa and 0.7 [0.3-1.2] kPa, p<0.005. CONCLUSIONS Amongst adult patients with TBI, the PaCO2-ETCO2 gradient was greater than previously reported values, particularly early in the patient journey, and when associated with concomitant chest injury. An increased PaCO2-ETCO2 gradient on admission was associated with increased mortality.
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Affiliation(s)
- Neil Sardesai
- Emmanuel College, University of Cambridge, Cambridge, United Kingdom
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre for Artificial Intelligence in Medicine, Cambridge, United Kingdom
| | - Owen Hibberd
- Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - James Price
- Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre for Artificial Intelligence in Medicine, Cambridge, United Kingdom
| | - Ed B. G. Barnard
- Emergency and Urgent Care Research in Cambridge (EUReCa), PACE Section, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, United Kingdom
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Wang C, Xing D, Zhou S, Fang F, Fu Y, Xu F. Electrical bioimpedance measurement and near-infrared spectroscopy in pediatric postoperative neurocritical care: a prospective observational study. Front Neurol 2023; 14:1190140. [PMID: 37416310 PMCID: PMC10322191 DOI: 10.3389/fneur.2023.1190140] [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] [Received: 03/20/2023] [Accepted: 05/30/2023] [Indexed: 07/08/2023] Open
Abstract
Background To investigate the clinical significance of the disturbance coefficient (DC) and regional cerebral oxygen saturation (rSO2) as obtained through the use of electrical bioimpedance and near-infrared spectroscopy (NIRS) in pediatric neurocritical care. Participants and methods We enrolled 45 pediatric patients as the injury group and 70 healthy children as the control group. DC was derived from impedance analysis of 0.1 mA-50 kHz current via temporal electrodes. rSO2 was the percentage of oxyhemoglobin measured from reflected NIR light on the forehead. DC and rSO2 were obtained at 6, 12, 24, 48 and 72 h after surgery for the injury group and during the health screening clinic visit for the control group. We compared DC and rSO2 between the groups, their changes over time within the injury group and their correlation with intracranial pressure (ICP), cerebral perfusion pressure (CPP), Glasgow coma scale (GCS) score, Glasgow outcome scale (GOS) score, and their ability to diagnose postoperative cerebral edema and predict poor prognosis. Results DC and rSO2 were significantly lower in the injury group than in the control group. In the injury group, ICP increased over the monitoring period, while DC, CPP and rSO2 decreased. DC was negatively correlated with ICP and positively correlated with GCS score and GOS score. Additionally, lower DC values were observed in patients with signs of cerebral edema, with a DC value of 86.5 or below suggesting the presence of brain edema in patients aged 6-16 years. On the other hand, rSO2 was positively correlated with CPP, GCS score, and GOS score, with a value of 64.4% or below indicating a poor prognosis. Decreased CPP is an independent risk factor for decreased rSO2. Conclusion DC and rSO2 monitoring based on electrical bioimpedance and near-infrared spectroscopy not only reflect the degree of brain edema and oxygenation, but also reflect the severity of the disease and predict the prognosis of the patients. This approach offers a real-time, bedside, and accurate method for assessing brain function and detecting postoperative cerebral edema and poor prognosis.
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Affiliation(s)
- Chenhao Wang
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Dianwei Xing
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Shuoyan Zhou
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yueqiang Fu
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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3
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Asehnoune K, Rooze P, Robba C, Bouras M, Mascia L, Cinotti R, Pelosi P, Roquilly A. Mechanical ventilation in patients with acute brain injury: a systematic review with meta-analysis. Crit Care 2023; 27:221. [PMID: 37280579 PMCID: PMC10242967 DOI: 10.1186/s13054-023-04509-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/25/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVE To describe the potential effects of ventilatory strategies on the outcome of acute brain-injured patients undergoing invasive mechanical ventilation. DESIGN Systematic review with an individual data meta-analysis. SETTING Observational and interventional (before/after) studies published up to August 22nd, 2022, were considered for inclusion. We investigated the effects of low tidal volume Vt < 8 ml/Kg of IBW versus Vt > = 8 ml/Kg of IBW, positive end-expiratory pressure (PEEP) < or > = 5 cmH2O and protective ventilation (association of both) on relevant clinical outcomes. POPULATION Patients with acute brain injury (trauma or haemorrhagic stroke) with invasive mechanical ventilation for ≥ 24 h. MAIN OUTCOME MEASURES The primary outcome was mortality at 28 days or in-hospital mortality. Secondary outcomes were the incidence of acute respiratory distress syndrome (ARDS), the duration of mechanical ventilation and the partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio. RESULTS The meta-analysis included eight studies with a total of 5639 patients. There was no difference in mortality between low and high tidal volume [Odds Ratio, OR 0.88 (95%Confidence Interval, CI 0.74 to 1.05), p = 0.16, I2 = 20%], low and moderate to high PEEP [OR 0.8 (95% CI 0.59 to 1.07), p = 0.13, I2 = 80%] or protective and non-protective ventilation [OR 1.03 (95% CI 0.93 to 1.15), p = 0.6, I2 = 11]. Low tidal volume [OR 0.74 (95% CI 0.45 to 1.21, p = 0.23, I2 = 88%], moderate PEEP [OR 0.98 (95% CI 0.76 to 1.26), p = 0.9, I2 = 21%] or protective ventilation [OR 1.22 (95% CI 0.94 to 1.58), p = 0.13, I2 = 22%] did not affect the incidence of acute respiratory distress syndrome. Protective ventilation improved the PaO2/FiO2 ratio in the first five days of mechanical ventilation (p < 0.01). CONCLUSIONS Low tidal volume, moderate to high PEEP, or protective ventilation were not associated with mortality and lower incidence of ARDS in patients with acute brain injury undergoing invasive mechanical ventilation. However, protective ventilation improved oxygenation and could be safely considered in this setting. The exact role of ventilatory management on the outcome of patients with a severe brain injury needs to be more accurately delineated.
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Affiliation(s)
- Karim Asehnoune
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France.
- Department of Anaesthesia and Critical Care, Hôtel-Dieu, University Hospital of Nantes, 1 Place Alexis Ricordeau, 44093, Nantes, France.
| | - Paul Rooze
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
| | - Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Marwan Bouras
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
| | - Luciana Mascia
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
| | - Raphaël Cinotti
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, University of Genoa, Genoa, Italy
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, Pôle Anesthésie Réanimations, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093, Nantes, France
- Nantes Université, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
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Liu S, Tian H, Niu Y, Yu C, Xie L, Jin Z, Niu W, Ren J, Fu L, Yao Z. Combined cell grafting and VPA administration facilitates neural repair through axonal regeneration and synaptogenesis in traumatic brain injury. Acta Biochim Biophys Sin (Shanghai) 2022; 54:1289-1300. [PMID: 36148950 PMCID: PMC9828309 DOI: 10.3724/abbs.2022123] [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] [Indexed: 12/29/2022] Open
Abstract
Neuronal regeneration and functional recovery are severely compromised following traumatic brain injury (TBI). Treatment options, including cell transplantation and drug therapy, have been shown to benefit TBI, although the underlying mechanisms remain elusive. In this study, neural stem cells (NSCs) are transplanted into TBI-challenged mice, together with olfactory ensheathing cells (OECs) or followed by valproic acid (VPA) treatment. Both OEC grafting and VPA treatment facilitate the differentiation of NSCs into neurons (including endogenous and exogenous neurons) and significantly attenuate neurological functional defects in TBI mice. Combination of NSCs with OECs or VPA administration leads to overt improvement in axonal regeneration, synaptogenesis, and synaptic plasticity in the cerebral cortex in TBI-challenged mice, as shown by retrograde corticospinal tract tracing, electron microscopy, growth-associated protein 43 (GAP43), and synaptophysin (SYN) analyses. However, these beneficial effects of VPA are reversed by local delivery of N-methyl-D-aspartate (NMDA) into tissues surrounding the injury epicenter in the cerebral cortex, accompanied by a pronounced drop in axons and synapses in the brain. Our findings reveal that increased axonal regeneration and synaptogenesis evoked by cell grafting and VPA fosters neural repair in a murine model of TBI. Moreover, VPA-induced neuroprotective roles are antagonized by exogenous NMDA administration and its concomitant decrease in the number of neurons of local brain, indicating that increased neurons induced by VPA treatment mediate axonal regeneration and synaptogenesis in mice after TBI operation. Collectively, this study provides new insights into NSC transplantation therapy for TBI.
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Affiliation(s)
- Sujuan Liu
- Department of Anatomy and EmbryologySchool of Basic Medical ScienceTianjin Medical UniversityTianjin300070China
| | - Haili Tian
- School of KinesiologyShanghai University of SportShanghai200438China
| | - Yanmei Niu
- Department of RehabilitationSchool of Medical TechnologyTianjin Medical UniversityTianjin300070China
| | - Chunxia Yu
- Department of Physiology and PathophysiologySchool of Basic Medical ScienceTianjin Medical UniversityTianjin300070China
| | - Lingjian Xie
- Department of Physiology and PathophysiologySchool of Basic Medical ScienceTianjin Medical UniversityTianjin300070China
| | - Zhe Jin
- Tianjin Yaohua Binhai SchoolTianjin300000China
| | - Wenyan Niu
- Key Laboratory of Immune Microenvironment and Disease (Ministry of Education)Department of ImmunologySchool of Basic Medical ScienceTianjin Medical UniversityTianjin300070China
| | - Jun Ren
- Department of CardiologyZhongshan Hospital Fudan UniversityShanghai Institute of Cardiovascular DiseasesShanghai200032China,Department of Laboratory Medicine and PathologyUniversity of WashingtonSeattleWA98195USA,Correspondence address. Tel: +86-22-83336819; (Z.Y.) / Tel: +86-22-83336107; (L.F.) / Tel: +86-21-64041990; (J.R.) @
| | - Li Fu
- Department of RehabilitationSchool of Medical TechnologyTianjin Medical UniversityTianjin300070China,Department of Physiology and PathophysiologySchool of Basic Medical ScienceTianjin Medical UniversityTianjin300070China,Correspondence address. Tel: +86-22-83336819; (Z.Y.) / Tel: +86-22-83336107; (L.F.) / Tel: +86-21-64041990; (J.R.) @
| | - Zhi Yao
- Key Laboratory of Immune Microenvironment and Disease (Ministry of Education)Department of ImmunologySchool of Basic Medical ScienceTianjin Medical UniversityTianjin300070China,Correspondence address. Tel: +86-22-83336819; (Z.Y.) / Tel: +86-22-83336107; (L.F.) / Tel: +86-21-64041990; (J.R.) @
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5
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Rass V, Bogossian EG, Ianosi BA, Peluso L, Kofler M, Lindner A, Schiefecker AJ, Putnina L, Gaasch M, Hackl WO, Beer R, Pfausler B, Taccone FS, Helbok R. The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study. Ann Intensive Care 2021; 11:176. [PMID: 34914011 PMCID: PMC8677880 DOI: 10.1186/s13613-021-00960-z] [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: 08/08/2021] [Accepted: 11/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring. Methods This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m2; global end-diastolic index, GEDI 680–800 mL/m2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (PbtO2) targeted protocol to prevent brain tissue hypoxia (BTH, PbtO2 < 20 mmHg). To assess the association between CI and PbtO2 and the effect of fluid challenges on CI and PbtO2, we used generalized estimating equations to account for repeated measurements. Results Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m2 on day 4). Higher CI levels were associated with higher PbtO2 levels (Wald = 14.2; p < 0.001). Neither daily fluid input nor fluid balance was associated with absolute PbtO2 levels (p = 0.94 and p = 0.85, respectively) or the occurrence of BTH (p = 0.68 and p = 0.71, respectively). PbtO2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. PbtO2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p = 0.002), but not when all boluses were considered (p = 0.154). Conclusions In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve PbtO2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00960-z.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner O Hackl
- Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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6
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Robba C. Cerebral Oxygenation: An Additional Target for the Management of Patients with Traumatic Brain Injury. Neurocrit Care 2021; 36:339-340. [PMID: 34820779 DOI: 10.1007/s12028-021-01396-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- Istituto di ricovero e cura a carattere scientifico (IRCCS) for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy.
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7
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Acevedo-Aguilar L, Gaitán-Herrera G, Reina-Rivero R, Lozada-Martínez ID, Bohorquez-Caballero A, Paéz-Escallón N, Del Pilar Zambrano-Arenas MD, Ortega-Sierra MG, Moscote-Salazar LR, Janjua T. Pulmonary injury as a predictor of cerebral hypoxia in traumatic brain injury: from physiology to physiopathology. J Neurosurg Sci 2021; 66:251-257. [PMID: 34763389 DOI: 10.23736/s0390-5616.21.05468-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Traumatic brain injury is caused by mechanical forces impacting the skull and its internal structures and constitutes one of the main causes of morbidity and mortality in the world. Clinically, severe traumatic brain injury is associated with the development of acute lung injury and so far, few studies have evaluated the cellular, molecular and immunological mechanisms involved in this pathophysiological process. Knowing and investigating these mechanisms allows us to correlate pulmonary injury as a predictor of cerebral hypoxia in traumatic brain injury and to use this finding in decision making during clinical practice. This review aims to provide evidence on the importance of the pathophysiology of traumatic brain injury-acute lung injury, and thus confirm its role as a predictor of cerebral hypoxia, helping to establish an appropriate therapeutic strategy to improve functional outcomes and reduce mortality.
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Affiliation(s)
- Laura Acevedo-Aguilar
- Medical and Surgical Research Center, School of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gustavo Gaitán-Herrera
- Medical and Surgical Research Center, School of Medicine, University of Cartagena, Cartagena, Colombia
| | - Randy Reina-Rivero
- Medical and Surgical Research Center, School of Medicine, University of Cartagena, Cartagena, Colombia
| | - Ivan D Lozada-Martínez
- Medical and Surgical Research Center, School of Medicine, University of Cartagena, Cartagena, Colombia - .,Colombian Clinical Research Group in Neurocritical Care, School of Medicine, University of Cartagena, Cartagena, Colombia.,Latin American Council of Neurocritical Care, Cartagena, Colombia.,Future Surgeons Chapter, Colombian Surgery Association, Bogotá, Colombia
| | | | | | | | - Michael G Ortega-Sierra
- Medical and Surgical Research Center, School of Medicine, Corporación Universitaria Rafael Nuñez, Cartagena, Colombia
| | - Luis R Moscote-Salazar
- Medical and Surgical Research Center, School of Medicine, University of Cartagena, Cartagena, Colombia.,Colombian Clinical Research Group in Neurocritical Care, School of Medicine, University of Cartagena, Cartagena, Colombia.,Latin American Council of Neurocritical Care, Cartagena, Colombia
| | - Tariq Janjua
- Intensive Care, Regions Hospital, Saint Paul, MN, USA
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8
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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9
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Robba C, Ball L, Battaglini D, Cardim D, Moncalvo E, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Rocco PRM, Matta BF, Pelosi P. Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2021; 25:111. [PMID: 33741052 PMCID: PMC7978164 DOI: 10.1186/s13054-021-03537-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. METHODS This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. RESULTS Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57-69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51-54]% vs. 49 [47-50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56-71] to 82 [76-87] mmHg, p = 0.005) and rSO2 (from 53 [52-54]% to 60 [59-64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67-73] to 72 [67-73] mmHg, p = 0.015) and rSO2 (from 53 [51-56]% to 57 [55-59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75-79] to 64 [60-70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56-65]% vs. 56 [53-62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). CONCLUSIONS Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Denise Battaglini
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas, Austin, USA
| | - Emanuela Moncalvo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Iole Brunetti
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Daniele R. Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa , Italy
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicolò Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Basil F. Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- IRCCS for Oncology and Neuroscience, Ospedale Policlinico San Martino, Genoa, Italy
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