Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO

Joram, Nicolas; Beqiri, Erta; Pezzato, Stefano; Moscatelli, Andrea; Robba, Chiara; Liet, Jean Michel; Chenouard, Alexis; Bourgoin, Pierre; Czosnyka, Marek; Leger, Pierre‐Louis; Smielewski, Peter

doi:10.1007/s12028-021-01201-8

Cited by 10 publications

(18 citation statements)

References 46 publications

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“… 11 , 30 In a recent study including 30 children supported by ECMO for all indications, we have shown that the level of PaCO 2 was positively correlated with the upper limit of CA, supporting that hypothesis of a protective effect of hypercapnia on CA, in case of high blood pressure and nonpulsatile flow. 31 However, this study did not investigate the relationship between PaCO 2 changes and CA. Nevertheless, as children supported by ECMO are frequently exposed to dramatic blood pressure increase and PaCO 2 variations at the same time after its onset, this result appears clinically relevant.…”

Section: Discussionmentioning

confidence: 91%

Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation

Joram

Rozé

Tonna³

et al. 2022

ASAIO Journal

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The primary objective was to investigate the association between partial pressure of carbon dioxide (PaCO2) change after extracorporeal membrane oxygenation (ECMO) initiation and neurologic outcome in neonates treated for respiratory failure. A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database including newborns supported by ECMO for respiratory indication during 2015–2020. The closest Pre-ECMO (Pre-ECMO PaCO2) and at 24 hours after ECMO initiation (H24 PaCO2) PaCO2 values allowed to calculate the relative change in PaCO2 (Rel Δ PaCO2 = [H24 PaCO2 – Pre-ECMO PaCO2]/Pre-ECMO PaCO2). The primary outcome was the onset of any acute neurologic event (ANE), defined as cerebral bleeding, ischemic stroke, clinical or electrical seizure, or brain death during ECMO. We included 3,583 newborns (median age 1 day [interquartile range {IQR}, 1–3], median weight 3.2 kg [IQR, 2.8–3.6]) from 198 ELSO centers. The median Rel Δ PaCO2 value was −29.9% [IQR, −46.2 to −8.5]. Six hundred nine (17%) of them had ANE (405 cerebral bleedings, 111 ischemic strokes, 225 seizures, and 6 brain deaths). Patients with a decrease of PaCO2 > 50% were more likely to develop ANE than others (odds ratio [OR] 1.78, 95% confidence interval [CI], 1.31–2.42, p < 0.001). This was still observed after adjustment for all clinically relevant confounding factors (adjusted OR 1.94, 95% CI, 1.29–2.92, p = 0.001). A significant decrease in PaCO2 after ECMO start is associated with ANE among neonates requiring ECMO for respiratory failure. Cautious PaCO2 decrease should be considered after start of ECMO therapy.

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Section: Discussionmentioning

confidence: 91%

Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation

Joram

Rozé

Tonna³

et al. 2022

ASAIO Journal

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“…In this context, rSO 2 could potentially be applied as surrogate of CBF, as NIRS- similarly to TCD- is a low cost, easy available, and safe neuromonitoring tool ( 27 ). For example, NIRS has been previously used for the dynamic assessment of CA, with promising results, but several concerns have been raised regarding its routine use ( 7 , 8 , 29 , 30 ). In particular, as NIR light penetrates skin, subcutaneous fat, skull, and underlying muscles and brain tissue, the absorption of light from chromophores depends on both the changes in oxygenated and deoxygenated haemoglobin, and, therefore, from both the arteriolar and venular beds.…”

Section: Discussionmentioning

confidence: 99%

The Use of Different Components of Brain Oxygenation for the Assessment of Cerebral Haemodynamics: A Prospective Observational Study on COVID-19 Patients

et al. 2021

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Introduction: The role of near-infrared spectroscopy (NIRS) for the evaluation of cerebral haemodynamics is gaining increasing popularity because of its noninvasive nature. The aim of this study was to evaluate the role of the integral components of regional cerebral oxygenation (rSO2) measured by NIRS [i.e., arterial-oxyhemoglobin (O2Hbi) and venous-deoxyhemoglobin (HHbi)-components], as indirect surrogates of cerebral blood flow (CBF) in a cohort of critically ill patients with coronavirus disease 2019 (COVID-19). We compared these findings to the gold standard technique for noninvasive CBF assessment, Transcranial Doppler (TCD).Methods: Mechanically ventilated patients with COVID-19 admitted to the Intensive Care Unit (ICU) of Policlinico San Martino Hospital, Genova, Italy, who underwent multimodal neuromonitoring (including NIRS and TCD), were included. rSO2 and its components [relative changes in O2Hbi, HHbi, and total haemoglobin (cHbi)] were compared with TCD (cerebral blood flow velocity, CBFV). Changes (Δ) in CBFV and rSO2, ΔO2Hbi, ΔHHbi, and ΔcHbi after systemic arterial blood pressure (MAP) modifications induced by different manoeuvres (e.g., rescue therapies and haemodynamic manipulation) were assessed using mixed-effect linear regression analysis and repeated measures correlation coefficients. All values were normalised as percentage changes from the baseline (Δ%).Results: One hundred and four measurements from 25 patients were included. Significant effects of Δ%MAP on Δ%CBF were observed after rescue manoeuvres for CBFV, ΔcHbi, and ΔO2Hbi. The highest correlation was found between ΔCBFV and ΔΔO2Hbi (R = 0.88, p < 0.0001), and the poorest between ΔCBFV and ΔΔHHbi (R = 0.34, p = 0.002).Conclusions: ΔO2Hbi had the highest accuracy to assess CBF changes, reflecting its role as the main component for vasomotor response after changes in MAP. The use of indexes derived from the different components of rSO2 can be useful for the bedside evaluation of cerebral haemodynamics in mechanically ventilated patients with COVID-19.

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“…Autoregulation is also strongly impacted in patients with a large change in blood pressure (7)(8)(9). Joram et al (10) demonstrated disruption in cerebral autoregulation during hypercapnia and cautioned particularly about the risk of blood pressure changes in pediatric ECMO. Furthermore, studies in neonates and adults have demonstrated that the magnitude of Paco 2 change after initiation of ECMO was associated with mortality (11,12).…”

mentioning

confidence: 99%

Early Changes in Arterial Partial Pressure of Carbon Dioxide and Blood Pressure After Starting Extracorporeal Membrane Oxygenation in Children: Extracorporeal Life Support Organization Database Study of Neurologic Complications*

Shah

Shanmugam

et al. 2023

Pediatric Critical Care Medicine

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Objective: Neurologic complications in pediatric patients supported by extracorporeal membrane oxygenation (ECMO) are common and lead to morbidity and mortality; however, few modifiable factors are known. Design: Retrospective study of the Extracorporeal Life Support Organization registry (2010–2019). Setting: Multicenter international database Patients: Pediatric patients receiving ECMO (2010–2019) for all indications and any mode of support. Interventions: None. Measurements and Main Results: We investigated if early relative change in Paco 2 or mean arterial blood pressure (MAP) soon after starting ECMO was associated with neurologic complications. The primary outcome of neurologic complications was defined as a report of seizures, central nervous system infarction or hemorrhage, or brain death. All-cause mortality (including brain death) was used as a secondary outcome. Out of 7,270 patients, 15.6% had neurologic complications. Neurologic complications increased when the relative Paco 2 decreased by greater than 50% (18.4%) or 30–50% (16.5%) versus those who had a minimal change (13.9%, p < 0.01 and p = 0.046). When the relative MAP increased greater than 50%, the rate of neurologic complications was 16.9% versus 13.1% those with minimal change (p = 0.007). In a multivariable model adjusting for confounders, a relative decrease in Paco 2 greater than 30% was independently associated with greater odds of neurologic complication (odds ratio [OR], 1.25; 95% CI, 1.07–1.46; p = 0.005). Within this group, with a relative decrease in Paco 2 greater than 30%, the effects of increased relative MAP increased neurologic complications (0.05% per BP Percentile; 95% CI, 0.001–0.11; p = 0.05). Conclusions: In pediatric patients, a large decrease in Paco 2 and increase in MAP following ECMO initiation are both associated with neurologic complications. Future research focusing on managing these issues carefully soon after ECMO deployment can potentially help to reduce neurologic complications.

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Impact of Arterial Carbon Dioxide and Oxygen Content on Cerebral Autoregulation Monitoring Among Children Supported by ECMO

Cited by 10 publications

References 46 publications

Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation

Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation

The Use of Different Components of Brain Oxygenation for the Assessment of Cerebral Haemodynamics: A Prospective Observational Study on COVID-19 Patients

Early Changes in Arterial Partial Pressure of Carbon Dioxide and Blood Pressure After Starting Extracorporeal Membrane Oxygenation in Children: Extracorporeal Life Support Organization Database Study of Neurologic Complications*

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