Using the relationship between brain tissue regional saturation of oxygen and mean arterial pressure to determine the optimal mean arterial pressure in patients following cardiac arrest: A pilot proof-of-concept study

Sekhon, Mypinder S.; Smielewski, Peter; Bhate, Tahara D.; Brasher, Penelope M. A.; Foster, Denise; Menon, David; Gupta, Arun Kumar; Czosnyka, Marek; Henderson, William R.; Gin, Kenneth; Wong, Graham C.; Griesdale, Donald

doi:10.1016/j.resuscitation.2016.05.019

Cited by 70 publications

(58 citation statements)

References 34 publications

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“…indicate that wavelet NIRS indices may be accurate methods to monitor autoregulation with lower signal variation than commonly used correlation indices [2][3][4] in pediatric cardiac arrest.…”

Section: Discussionmentioning

confidence: 97%

Comparison of wavelet and correlation indices of cerebral autoregulation in a pediatric swine model of cardiac arrest

Liu

Brady

et al. 2020

Sci Rep

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Existing cerebrovascular blood pressure autoregulation metrics have not been translated to clinical care for pediatric cardiac arrest, in part because signal noise causes high index time-variability. We tested whether a wavelet method that uses near-infrared spectroscopy (NIRS) or intracranial pressure (ICP) decreases index variability compared to that of commonly used correlation indices. We also compared whether the methods identify the optimal arterial blood pressure (ABPopt) and lower limit of autoregulation (LLA). 68 piglets were randomized to cardiac arrest or sham procedure with continuous monitoring of cerebral blood flow using laser Doppler, NIRS and ICP. The arterial blood pressure (ABP) was gradually reduced until it dropped to below the LLA. Several autoregulation indices were calculated using correlation and wavelet methods, including the pressure reactivity index (PRx and wPRx), cerebral oximetry index (COx and wCOx), and hemoglobin volume index (HVx and wHVx). Wavelet methodology had less index variability with smaller standard deviations. Both wavelet and correlation methods distinguished functional autoregulation (ABP above LLA) from dysfunctional autoregulation (ABP below the LLA). Both wavelet and correlation methods also identified ABPopt with high agreement. Thus, wavelet methodology using NIRS may offer an accurate vasoreactivity monitoring method with reduced signal noise after pediatric cardiac arrest.Cerebrovascular autoregulation constrains cerebral blood flow across fluctuations in cerebral perfusion pressure (CPP). It is mediated by vasoreactivity with changes in cerebrovascular resistance. Autoregulation may become dysfunctional after cardiac arrest, traumatic brain injury, and elevated intracranial pressure (ICP) 1-6 with shifts in the limits of blood pressure autoregulation. Methods to identify and target the blood pressure range that supports autoregulation could reduce secondary neurologic injury.The optimal mean arterial blood pressure (ABPopt) at which autoregulatory vasoreactivity is most robust varies after pediatric hypoxic brain injury 4,7-9 . Targeting the optimal CPP may improve neurologic outcomes after adult traumatic brain injury 5,10 . However, the ABPopt must be used after pediatric cardiac arrest because invasive ICP monitoring is not routinely performed in this population. Maintaining blood pressure close to ABPopt is associated with less neurologic injury in infants and children at risk of hypoxic brain injury, including those resuscitated from cardiac arrest 4,11 and those with hypoxic-ischemic encephalopathy 7-9 , prematurity 12 , or moyamoya vasculopathy 13 .

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Section: Discussionmentioning

confidence: 97%

Comparison of wavelet and correlation indices of cerebral autoregulation in a pediatric swine model of cardiac arrest

Liu

Brady

et al. 2020

Sci Rep

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“…Although higher COx was associated with nonsurvivors, there was no association between rSO 2 and mortality. Recently, our research team demonstrated feasibility of monitoring COx in real time and identification of optimal MAP prospectively in 20 patients after CA [55]. Subjects spent approximately 50% of time outside a ±5 mmHg range from the optimal MAP, and, importantly, the optimal MAP was consistently identified in 19 of 20 subjects.…”

Section: Secondary Injurymentioning

confidence: 99%

“…Increased cerebral metabolism, hyperemic blood flow, and increased ICP are additional downstream consequences of uncontrolled hyperthermia in HIBI [3]. Recently, we showed that hyperthermia is associated with dysfunctional autoregulation in patients with HIBI [55]. …”

Section: Secondary Injurymentioning

confidence: 99%

Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: a “two-hit” model

2017

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Hypoxic ischemic brain injury (HIBI) after cardiac arrest (CA) is a leading cause of mortality and long-term neurologic disability in survivors. The pathophysiology of HIBI encompasses a heterogeneous cascade that culminates in secondary brain injury and neuronal cell death. This begins with primary injury to the brain caused by the immediate cessation of cerebral blood flow following CA. Thereafter, the secondary injury of HIBI takes place in the hours and days following the initial CA and reperfusion. Among factors that may be implicated in this secondary injury include reperfusion injury, microcirculatory dysfunction, impaired cerebral autoregulation, hypoxemia, hyperoxia, hyperthermia, fluctuations in arterial carbon dioxide, and concomitant anemia.Clarifying the underlying pathophysiology of HIBI is imperative and has been the focus of considerable research to identify therapeutic targets. Most notably, targeted temperature management has been studied rigorously in preventing secondary injury after HIBI and is associated with improved outcome compared with hyperthermia. Recent advances point to important roles of anemia, carbon dioxide perturbations, hypoxemia, hyperoxia, and cerebral edema as contributing to secondary injury after HIBI and adverse outcomes. Furthermore, breakthroughs in the individualization of perfusion targets for patients with HIBI using cerebral autoregulation monitoring represent an attractive area of future work with therapeutic implications.We provide an in-depth review of the pathophysiology of HIBI to critically evaluate current approaches for the early treatment of HIBI secondary to CA. Potential therapeutic targets and future research directions are summarized.

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“…There is no standard value of MAP that would be appropriate for all hemodynamic targets (Ameloot et al, 2015). Due to an impaired CVAR, we could control MAP by measuring rSO 2 to avoid brain ischemia for PCAS management (Sekhon et al, 2016).…”

Section: Discussionmentioning

confidence: 99%

Parameters Influencing Brain Oxygen Measurement by Regional Oxygen Saturation in Postcardiac Arrest Patients with Targeted Temperature Management

Sakurai

Ihara

Tagami

et al. 2020

Therapeutic Hypothermia and Temperature Management

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In several studies, regional cerebral oxygen saturation (rSO 2 ) has been measured in patients with postcardiac arrest syndrome (PCAS) to analyze the brain's metabolic status. However, the significance of rSO 2 in PCAS patients remains unclear. In the present study, we investigated the relationship between rSO 2 and physiological parameters. Comatose survivors of out-of-hospital PCAS with targeted temperature management (TTM) at 34°C for 24 hours were included. All patients were monitored for their rSO 2 and additional parameters (arterial oxygen saturation [SaO 2 ], hemoglobin [Hb], mean arterial pressure [MAP], arterial carbon dioxide pressure [PaCO 2 ], and body temperature]) measured at the start of monitoring and 24 and 48 hours after return of spontaneous circulation (ROSC). Patients were divided into favorable and unfavorable groups, and the correlation between rSO 2 and these physiological parameters was evaluated by multiple regression analysis. Forty-nine patients were included in the study, with 15 in the favorable group and 34 in the unfavorable group. There was no significant difference in the rSO 2 value between the two groups at any time point. The multiple regression analysis of the favorable group revealed a moderate correlation between rSO 2 and SaO 2 , Hb, and PaCO 2 only at 24 hours (coefficients: 0.482, 0.422, and 0.531, respectively), whereas that of the unfavorable group revealed moderate correlations between rSO 2 and Hb values at all time points, PaCO 2 at 24 hours and MAP at 24 and 48 hours. rSO 2 was moderately correlated to MAP in unfavorable patients. To optimize brain oxygen metabolic balance for PCAS patients with TTM measuring rSO 2 , we suggest total evaluation of each parameters of SaO 2 , Hb, MAP, and PaCO 2 .

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Using the relationship between brain tissue regional saturation of oxygen and mean arterial pressure to determine the optimal mean arterial pressure in patients following cardiac arrest: A pilot proof-of-concept study

Abstract: We demonstrated the feasibility to determine a MAPOPT using cerebral oximetry in patients after cardiac arrest.

Cited by 70 publications

References 34 publications

Comparison of wavelet and correlation indices of cerebral autoregulation in a pediatric swine model of cardiac arrest

Comparison of wavelet and correlation indices of cerebral autoregulation in a pediatric swine model of cardiac arrest

Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: a “two-hit” model

Parameters Influencing Brain Oxygen Measurement by Regional Oxygen Saturation in Postcardiac Arrest Patients with Targeted Temperature Management

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