Monitoring of cerebrovascular pressure reactivity in children may predict neurologic outcome after hypoxic-ischemic brain injury

Abstract

Objectives Impaired cerebral blood flow is a first-line reason of ischemic-hypoxic brain injury in children. The principal goal of intensive care management is to detect and prevent further cerebral blood flow deficits. This can be achieved by actively managing cerebral perfusion pressure (CPP) using input from cerebrovascular autoregulation (CAR). The main objective of the current study was to investigate CAR after cardiac arrest in children. Methods Nineteen consecutive children younger than 18 years after cardiopulmonary resuscitation, in whom intracranial pressure (ICP) was continuously measured, were included. Blood pressure and ICP were continuously monitored via ICM + software and actively managed using the pressure reactivity index (PRx) to achieve and maintain an optimal CPP. Outcome was scored using the extended Glasgow outcome scale (eGOS) at discharge and 6 months. Results Eight children died in hospital. At 6 months, further 4 children had an unfavorable (eGOS1–4) and 7 a favorable (eGOS5–8) outcome. Over the entire monitoring period, we found an elevated ICP (24.5 vs 7.4 mmHg), a lower CPP (50.3 vs 66.2 mmHg) and a higher PRx (0.24 vs − 0.01), indicating impaired CAR, in patients with unfavorable outcome. The dose of impaired autoregulation was significantly higher in unfavorable outcome (54.6 vs 29.3%). Analyzing only the first 72 h after cardiac arrest, ICP ≥ 10 mmHg and PRx > 0.2 correlated to unfavorable outcome. Conclusions Significant doses of impaired CAR within 72 h after resuscitation are associated with unfavorable outcome. The inability to restore autoregulation despite active attempts to do so as well as an elevated ICP may serve as a bad prognostic sign indicating a severe initial hypoxic-ischemic brain injury.

Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know

“…Impaired CA is frequent in ABI, affecting 30 to 40% of children with sTBI 131,134,135 and 30 to 50% of patients with hypoxicischemic brain injury (HIBI). [136][137][138] It increases vulnerability to secondary insults and is independently associated with worse outcomes. 132,[139][140][141][142][143][144][145][146][147] The most studied CA assessment method is the pressure reactivity index (PRx), which uses spontaneous variations in mean arterial pressure (MAP) to calculate a moving correlation coefficient (À1 to þ1) between ICP and MAP.…”

Intracranial Pressure, Autoregulation, and Cerebral Perfusion in Infants With Nonsyndromic Craniosynostosis at the Time of Surgical Correction

“…Positive values imply an increasingly linear relationship between MAP and ICP and impaired autoregulation and are associated with poor outcomes after trauma or brain injury. 19-22…”

“…Positive values imply an increasingly linear relationship between MAP and ICP and impaired autoregulation and are associated with poor outcomes after trauma or brain injury. [19][20][21][22] Owing to the inconsistency of data regarding a possible influence of ICP in monosutural craniosynostosis in addition to aesthetic aspects, indications for surgery and consulting with parents of affected infants can be challenging regarding the role of ICP. Therefore, this study aimed to investigate ICP, cerebral perfusion parameters, and CAR in a homogenous set of children with nonsyndromic craniosynostosis at the time of the first cranial vault correction.…”