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Xie J, Carbonara AR, Al-Battashi AW, Ross-White A, Boyd JG. Individualized mean arterial pressure targets in critically ill patients guided by non-invasive cerebral-autoregulation: a scoping review. Crit Care 2025; 29:196. [PMID: 40380314 PMCID: PMC12084981 DOI: 10.1186/s13054-025-05432-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2025] [Accepted: 04/23/2025] [Indexed: 05/19/2025] Open
Abstract
BACKGROUND Current guidelines recommend a uniform mean arterial pressure (MAP) target for resuscitating critically ill patients; for example, 65 mmHg for patients with sepsis and post-cardiac arrest. However, since cerebral autoregulation capacity likely varies widely in patients, uniform target may be insufficient in maintaining cerebral perfusion. Personalized MAP targets, based on a non-invasive determination of cerebral autoregulation, may optimize perfusion and reduce complications. OBJECTIVES This scoping review summarizes the numerical values, feasibility, and clinical data on personalized MAP targets in critically ill patients. The focus is on non-invasive monitoring, such as near-infrared spectroscopy and transcranial doppler ultrasound, due to their safety, practicality and applicability to patients with- and without brain injury. METHODS Following PRISMA-ScR guidelines, a systematic search of Ovid MedLine, Embase (Ovid), and the Cochrane Library (Wiley) was conducted on September 28, 2023. Two independent reviewers screened titles, abstracts, and full texts for eligibility and manually reviewed references. RESULTS Of 7,738 studies were identified, 49 met the inclusion criteria. Of these, 45 (92%) were observational and 4 (8%) were interventional. Patient populations included cardiac surgery (26, 53%), non-cardiac major surgery (4, 8%), cardiac arrest (8, 16%), brain injury (7, 14%), respiratory failure and shock (3, 6%), and sepsis (3, 6%). Optimal MAP was reported in 24 (49%), lower limit of autoregulation in 23 (47%), and upper limit of autoregulation in 10 studies (20%). Thirty-four studies reported partial data loss due to software failures, anomalous data, insufficient natural MAP fluctuation, and workflow barriers. Available randomized controlled trials (RCT) identified challenges with maintaining patients within their target range. Studies explored the associations between personalized MAP targets and a wide range of neurological and non-neurological outcomes, with the most significant and consistent associations identified for acute kidney injury and major morbidity and mortality. Ten studies investigated demographic predictors identifying only few predictors of personalized targets. CONCLUSION Preliminary investigations suggest considerable variability in personalized MAP targets, which may explain differences in clinical outcomes among critically ill populations. Key gaps remain, including a lack of observational studies in critically ill subpopulations other than cardiac surgery and well-designed RCTs. Resolving identified feasibility barriers might be crucial to successfully carrying out future studies.
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Affiliation(s)
- Jiale Xie
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Amanda Ross-White
- Queen's University Library, Queen's University, Kingston, ON, Canada
| | - J Gordon Boyd
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.
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Desebbe O, Berna A, Joosten A, Raphael D, Malapert G, Rolo D, Taccone FS, Gergele L. Impact of cardiopulmonary bypass flow on the lower limit of cerebral autoregulation during cardiac surgery: a randomized cross-over pilot study. J Clin Monit Comput 2025:10.1007/s10877-025-01290-2. [PMID: 40220213 DOI: 10.1007/s10877-025-01290-2] [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: 02/12/2025] [Accepted: 03/19/2025] [Indexed: 04/14/2025]
Abstract
Assessment of cerebral autoregulation is challenging under different hemodynamic conditions during cardiac surgery and must be rapidly calculated in order to optimize mean arterial pressure (MAP). Whether systemic flow during cardiopulmonary bypass impacts the lower limit of cerebral autoregulation (LLA) remains unclear. Forty patients requiring cardiac surgery were included in this randomized crossover study. Patients assigned to the conventional/high blood flow arm received 20 min of conventional cardiopulmonary bypass (CPB) blood flow (2.2 L/min.m-²) followed by 20 min of high blood flow (2.8 L/min.m-²), both during aortic cross clamping. Patients assigned to the high/conventional arm received the same flows but in reverse order. During each 20-minute period, MAP was gradually increased from 40 to 90 mmHg, while PaCO2, hematocrit, depth of anesthesia, central temperature and arterial oxygen tension were kept constant. Continuous cerebral blood flow velocities of the middle cerebral artery (Fv) were monitored using transcranial doppler. Cerebral autoregulation was calculated using a Pearson's correlation coefficient (Mean flow index, Mxa) between the MAP and Fv. Mxa values were then plotted across MAP ranges. The LLA was defined as the corresponding MAP value when Mxa initially decreased and crossed the threshold value of 0.4. A mixed model, including the LLA as the dependent variable, the CPB flow and period as fixed effects and patients as a random effect was used to compare conventional and high CPB flows. Thirty-seven patients were analyzed. The LLA mean difference between groups, adjusted on the period, was - 2.8 (SE 2.4) mmHg with 95% CI [-7.8, + 2.1 mmHg], p = 0.2538). 24% of patients presented an LLA < 65 mmHg during the conventional CPB flow phase versus 35% during the high CPB flow phase. Increasing the cardiopulmonary pump flow did not decrease the LLA during cardiac surgery.
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Affiliation(s)
- Olivier Desebbe
- Department of Anesthesiology and perioperative care, Ramsay Sante, Sauvegarde Clinic, Lyon, France.
- Department of Anesthesiology & Perioperative Medicine, Clinique de la Sauvegarde, 480 avenue Ben Gourion, Lyon, 69009, France.
| | - Antoine Berna
- Department of Anesthesiology and perioperative care, Ramsay Sante, Sauvegarde Clinic, Lyon, France
| | - Alexandre Joosten
- Department of Anesthesiology & Perioperative Care, University of California Los Angeles, Los Angeles, CA, 90095, USA
| | - Darren Raphael
- Department of Anesthesiology & Perioperative Care, University of California Irvine, Irvine, CA, 92868, USA
| | - Ghislain Malapert
- Department of Cardiac Surgery, Ramsay Sante, Sauvegarde Clinic, Lyon, France
| | - Dimitri Rolo
- Department of Anesthesiology and perioperative care, Ramsay Sante, Sauvegarde Clinic, Lyon, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Brussels, Belgium
| | - Laurent Gergele
- Department of Anesthesiology and Perioperative Care, Ramsay Sante, Hôpital Privé de la Loire, Saint-Etienne, France
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Bourgoin P, Beqiri E, Smielewski P, Chenouard A, Gaultier A, Sadones F, Gouedard U, Joram N, Amedro P. Optimal brain perfusion pressure derived from the continuous monitoring of cerebral autoregulation status during neonatal heart surgery under cardiopulmonary bypass in relation to brain injury: An observational study. Anaesth Crit Care Pain Med 2025; 44:101509. [PMID: 40154883 DOI: 10.1016/j.accpm.2025.101509] [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: 12/09/2024] [Revised: 02/17/2025] [Accepted: 02/19/2025] [Indexed: 04/01/2025]
Abstract
BACKGROUND Understanding cerebral blood flow regulation and later optimizing brain perfusion is part of neuroprotection during cardiopulmonary bypass (CPB) in neonates. METHODS A total of 38 neonates undergoing CPB were monitored using near-infrared spectrometry and mean arterial pressure (MAP). Cerebral autoregulation (CAR) was assessed through the continuous measurement of the Cerebral Oxygenation Index (COx), and CAR-derived metrics were determined by plotting averaged COx values by MAP: Optimal MAP (MAPopt), lower limit of CAR (LLA), upper limit of CAR (ULA). RESULTS Out of 38, 17 (45%) neonates exhibited moderate to severe brain lesions post-operatively. The onset of CPB was associated with CAR disruption (mean COx pre-CPB = 0.16 ± 0.11; during CPB: 0.39 ± 0.37, p < 0.001). A LLA was identified in 31 out of 38 (82%), 23 out of 38 (61%), and 14 out of 38 (37%) patients before, during, and after CPB, respectively. An ULA was identified in 29 out of 38 (76%), 22 out of 38 (58%), and 14 out of 38 (37%) patients in the same time frames. Patients with abnormal post-operative brain MRI spent more time below the LLA during CPB: 28.3% [17.1-32.9] versus 9.9% [6.9-18.5] in patients without detected brain injury, p = 0.039. No differences were observed regarding the time spent above the upper limit of autoregulation. CONCLUSION The study provides valuable insights into the intricate relationship between intraoperative cerebral hemodynamics and post-operative brain injury. Further research is warranted to explore potential interventions based on CAR-derived metrics during CPB in neonates. CLINICAL TRIAL REGISTRATION NUMBER Not applicable. PRIOR PRESENTATION Not applicable.
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Affiliation(s)
- Pierre Bourgoin
- IHU Liryc, Electrophysiology and Heart Modelling Institute, INSERM 1045, University of Bordeaux, Pessac, France; Pediatric Intensive Care Unit, Nantes University Hospital, Nantes, France; Department of Anesthesiology, Nantes University Hospital, Nantes, France.
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, Nantes University Hospital, Nantes, France
| | | | - Flavie Sadones
- Department of Pediatric Radiology, Nantes University Hospital, Nantes, France
| | - Ugo Gouedard
- Department of Anesthesiology, Nantes University Hospital, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, Nantes University Hospital, Nantes, France
| | - Pascal Amedro
- IHU Liryc, Electrophysiology and Heart Modelling Institute, INSERM 1045, University of Bordeaux, Pessac, France; Pediatric and Congenital Cardiology Department, M3C National Reference Center, Bordeaux University Hospital, Bordeaux, France
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Niezen CK, Modestini M, Massari D, Bos AF, Scheeren TWL, Struys MMRF, Vos JJ. Prognostic Value of Perioperative Near-Infrared Spectroscopy Monitoring for Postoperative Acute Kidney Injury in Pediatric Cardiac Surgery: A Systematic Review. Semin Cardiothorac Vasc Anesth 2025:10892532251316682. [PMID: 39928846 DOI: 10.1177/10892532251316682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2025]
Abstract
INTRODUCTION Postoperative acute kidney injury (AKI) is a common postoperative complication in cardiac surgery, with varying reported incidences and prognostic factors. Renal hypoperfusion is believed to be a key factor contributing to postoperative AKI. Near-infrared spectroscopy (NIRS) monitoring, which assesses regional tissue saturation (RSO2), has been suggested as a tool to predict postoperative AKI. The aim of this systematic review was to examine the prognostic value of perioperative NIRS monitoring in predicting postoperative AKI in pediatric patients. METHODS AND RESULTS After a systematic search in PubMed, EMBASE, and Cochrane library, twenty studies (1517 patients) were included. The inter-rater agreement on study quality was strong, yet a high risk of bias was identified. CONCLUSION The heterogeneity of the results-in part attributable to several potential confounding factors regarding study population, monitoring technique and the definition of AKI-together with the lack of a clear and consistent association between RSO2 values and AKI, currently preclude recommending NIRS monitoring as a reliable and valid clinical tool to "predict" AKI in the individual patient.
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Affiliation(s)
- Cornelia K Niezen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Anesthesiology, Isala Hospital, Zwolle, The Netherlands
| | - Marco Modestini
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dario Massari
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arend F Bos
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michel M R F Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Basic and Applied Medical Sciences, Ghent University, Gent; Belgium
| | - Jaap Jan Vos
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Ayers BC, Padrós-Valls R, Brownlee S, Steinhorn BS, Shann K, Osho A, Sundt TM, Aguirre AD. Prebypass Critical Closing Pressure Predicts Acute Kidney Injury After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2025; 39:437-446. [PMID: 39645444 DOI: 10.1053/j.jvca.2024.11.010] [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: 08/01/2024] [Revised: 11/04/2024] [Accepted: 11/06/2024] [Indexed: 12/09/2024]
Abstract
OBJECTIVES Optimal blood pressure goals during cardiopulmonary bypass (CPB) remain uncertain and new metrics to individualize perfusion targets are needed. Critical closing pressure (Pcrit) is a fundamental property of the arterial circulation related to vascular tone and represents the outflow pressure impacting flow across the systemic circulation. We examined Pcrit as a prognostic marker of acute kidney injury (AKI). DESIGN Retrospective cohort study. SETTING Single tertiary care hospital PARTICIPANTS: We included 1,038 adult cardiac surgery patients who underwent CPB. INTERVENTIONS Pcrit was calculated using arterial waveform data before initiation of CPB. Pcrit was examined in relation to incidence of stage 2 or higher postoperative AKI according to standard Kidney Disease Improving Global Outcomes definitions. MEASUREMENTS AND MAIN RESULTS Of the 1,038 patients included in the study, 50 (5%) experienced AKI. Patients who suffered AKI had significantly higher preoperative risk factors, including higher incidence of severe chronic kidney disease and higher Society of Thoracic Surgeons risk score (p < 0.01). They also had longer operative times and longer cross-clamp times (p < 0.01). All patients were maintained at similar mean arterial pressure while on CPB. Patients who suffered AKI had a significantly higher prebypass Pcrit than those who did not (49.0 mmHg vs 44.1 mmHg; p = 0.018). In a multivariate regression, Pcrit remained a significant predictor, representing a 16% increased risk of AKI for each 5 mmHg increase in prebypass Pcrit (p = 0.011). CONCLUSIONS A higher prebypass Pcrit is associated with a significantly higher incidence of postoperative AKI. Future study is warranted to investigate using intraoperative Pcrit to determine a personalized blood pressure goal during CPB.
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Affiliation(s)
- Brian C Ayers
- Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Raimon Padrós-Valls
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Bioinformatics and Systems Biology, University of California, San Diego, San Diego, CA
| | - Sarah Brownlee
- Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Benjamin S Steinhorn
- Department of Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kenneth Shann
- Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Asishana Osho
- Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thoralf M Sundt
- Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aaron D Aguirre
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA.
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Chen X, Xie W, Li W, Gao J. Cerebral Oximetry Index-Guided Blood Pressure Management During Cardiopulmonary Bypass Reduces Postoperative Delirium in Patients with Acute Type A Aortic Dissection. J Cardiothorac Vasc Anesth 2025:S1053-0770(25)00029-1. [PMID: 39855957 DOI: 10.1053/j.jvca.2025.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2024] [Revised: 12/30/2024] [Accepted: 01/06/2025] [Indexed: 01/27/2025]
Abstract
OBJECTIVE(S) To investigate whether cerebral oximetry index (COx)-guided blood pressure management during cardiopulmonary bypass (CPB) could reduce postoperative delirium (POD) in patients undergoing acute type A aortic dissection (ATAAD) repair. DESIGN A prospective, randomized controlled trial. SETTING Patients undergoing ATAAD repair with CPB. PARTICIPANTS 157 patients with ATAAD were randomly assigned to COx-guided management (n = 76) or conventional blood pressure management (n = 81) during CPB. INTERVENTIONS COx-guided blood pressure management (intervention group) versus conventional blood pressure management (control group) during CPB. MEASUREMENTS AND MAIN RESULTS The primary outcome was POD incidence within the first 7 postoperative days (significantly lower in the COx-guided group: 15% v 30%, p = 0.039). Secondary outcomes included lower delirium severity (Delirium Rating Scale-Revised-98 score: 5 v 10, p = 0.033), shorter POD duration (0 v 2 days, p = 0.045), reduced postoperative cerebral infarction (1.3% v 8.6%, p = 0.037), and reduced acute kidney injury (27.6% v 43.2%, p = 0.042) in the COx-guided group. Shorter time to extubation (16.9 v 18.4 hours, p = 0.027) and reduced intensive care unit stay (7.3 v 8.2 days, p = 0.042) were observed in the COx-guided group. CONCLUSIONS COx-guided blood pressure management during CPB was associated with reduced incidence and severity of POD following ATAAD surgery. This approach also showed potential benefits in reducing postoperative complications and improving early recovery outcomes. Further multicenter studies are needed to confirm these findings.
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Affiliation(s)
- Xizhi Chen
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Wei Xie
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Weiwei Li
- School of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Ju Gao
- Department of Anesthesiology, The Yangzhou Clinical Medical College of Xuzhou Medical University, Yangzhou, Jiangsu Province, China.
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Gomez JR, Bhende BU, Mathur R, Gonzalez LF, Shah VA. Individualized autoregulation-guided arterial blood pressure management in neurocritical care. Neurotherapeutics 2025; 22:e00526. [PMID: 39828496 PMCID: PMC11840358 DOI: 10.1016/j.neurot.2025.e00526] [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: 11/08/2024] [Revised: 01/07/2025] [Accepted: 01/08/2025] [Indexed: 01/22/2025] Open
Abstract
Cerebral autoregulation (CA) is the physiological process by which cerebral blood flow is maintained during fluctuations in arterial blood pressure (ABP). There are various validated methods to measure CA, either invasively, with intracranial pressure or brain tissue oxygenation monitors, or noninvasively, with transcranial Doppler ultrasound or near-infrared spectroscopy. Utilizing these monitors, researchers have been able to discern CA patterns in several pathological states, such as but not limited to acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis, and post-cardiac arrest, and they have found CA to be altered in these patients. CA disturbances predispose patients suffering from these ailments to worse outcomes. Much focus has been placed on CA monitoring in these populations, with an emphasis on arterial blood pressure optimization. Many guidelines recommend universal static ABP targets; however, in patients with altered CA, these targets may make them susceptible to hypoperfusion and further neurological injury. Based on this observation, there has been much investigation on individualized ABP goals and their effect on clinical outcomes. The scope of this review includes (1) a summary of the physiology of CA in healthy adults; (2) a review of the evidence on CA monitoring in healthy individuals; (3) a summary of CA changes and its effect on outcomes in various diseased states including acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis and meningitis, post-cardiac arrest, hypoxic-ischemic encephalopathy, surgery, and moyamoya disease; and (4) a review of the current evidence on individualized ABP changes in various patient populations.
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Affiliation(s)
- Jonathan R Gomez
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA
| | - Bhagyashri U Bhende
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA
| | - Rohan Mathur
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, USA; Division of Vascular and Endovascular Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vishank A Shah
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, USA; Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, USA.
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Dhanyee AS, Parida S, Thangaswamy CR, Jha AK, Rajappa M, Munuswamy H, Mishra SK. Relationship between difference of preoperative and cardiopulmonary bypass mean arterial pressure, and acute kidney injury in cardiac surgical patients undergoing valve surgery. Perfusion 2025; 40:164-173. [PMID: 38182129 DOI: 10.1177/02676591231226161] [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] [Indexed: 01/07/2024]
Abstract
BACKGROUND Modifiable and non-modifiable factors contribute to development and progression of acute kidney injury (AKI) during cardiac surgery. We hypothesized that, the difference between preoperative mean arterial pressure (MAP) and the average mean arterial pressure maintained on cardiopulmonary bypass (CPB) would be strongly predictive of AKI. We also measured plasma Neutrophil gelatinase-associated lipocalin (NGAL), to establish its association with cardiac surgery associated-AKI (CSA-AKI). METHODS One hundred and twelve high-risk patients undergoing valve, and valve plus coronary artery bypass grafting (CABG) surgery under cardiopulmonary bypass (CPB) were included in this study. Delta mean arterial pressure (MAP) was calculated as the difference between the average of pre-operative and on-bypass MAP, and blood was sampled for NGAL levels, at baseline, and 6-h after CPB. Detailed data collection was done, tabulating most of the factors which might influence development of post-operative cardiac surgery associated-AKI (CSA-AKI). To define CSA-AKI within the first 24-h post-operatively, the Kidney Disease Improving Global Outcomes (KDIGO) classification was used. RESULTS Out of 112 patients, 44 (39.3%) developed CSA-AKI postoperatively. With an ROC analysis cut-off of delta MAP of more than 25.67 mmHg, 46.4% patients developed post-operative AKI, and the average CPB flows which were 1.8 ± 0.2 were not contributory to the development of early CSA-AKI. In our study, ELISA test for human NGAL was performed on serum samples, and the estimated cut-off value of 1661 ng/mL was found to be significantly associated with early CSA-AKI. CONCLUSIONS Delta MAP and CPB flows are not related to early post-surgical CSA-AKI in cases with prior high-risk elements. However, baseline serum NGAL, as well as its percent change during the early post-surgical period independently predicted the development of CSA-AKI. This implies that, there may be patients with a higher pre-operative preponderance to develop this complication, which could actually be delineated by the use of serum NGAL estimations at baseline.
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Affiliation(s)
- Anity Singh Dhanyee
- Department of Anaesthesiology & Critical Care, Sri Balaji Vidyapeeth (Deemed-to-be-University), Mahatma Gandhi Medical College & Research Institute, Puducherry, India
| | - Satyen Parida
- Department of Anaesthesiology & Critical Care, JIPMER, Puducherry, India
| | | | - Ajay Kumar Jha
- Department of Anaesthesiology & Critical Care, JIPMER, Puducherry, India
| | - Medha Rajappa
- Department of Biochemistry, JIPMER, Puducherry, India
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Meng L, Sun Y, Rasmussen M, Libiran NBS, Naiken S, Meacham KS, Schmidt JD, Lahiri NK, Han J, Liu Z, Adams DC, Gelb AW. Lassen's Cerebral Autoregulation Plot Revisited and Validated 65 Years Later: Impacts of Vasoactive Drug Treatment on Cerebral Blood Flow. Anesth Analg 2024:00000539-990000000-01026. [PMID: 39495668 DOI: 10.1213/ane.0000000000007280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2024]
Abstract
Niels Lassen's seminal 1959 cerebral autoregulation plot, a cornerstone in understanding the relationship between mean arterial pressure (MAP) and cerebral blood flow (CBF), was based on preexisting literature. However, this work has faced criticism for selective data presentation, leading to inaccurate interpretation. This review revisits and validates Lassen's original plot using contemporary data published since 2000. Additionally, we aim to understand the impact of vasoactive drug treatments on CBF, as Lassen's referenced studies used various drugs for blood pressure manipulation. Our findings confirm Lassen's concept of a plateau where CBF remains relatively stable across a specific MAP range in awake humans with normal brains. However, significant variations in cerebral autoregulation among different populations are evident. In critically ill patients and those with traumatic brain injury, the autoregulatory plateau dissipates, necessitating tight blood pressure control to avoid inadequate or excessive cerebral perfusion. A plateau is observed in patients anesthetized with intravenous agents but not with volatile agents. Vasopressor treatments have population-dependent effects, with contemporary data showing increased CBF in critically ill patients but not in awake humans with normal brains. Vasopressor treatment results in a greater increase in CBF during volatile than intravenous anesthesia. Modern antihypertensives do not significantly impact CBF based on contemporary data, exerting a smaller impact on CBF compared to historical data. These insights underscore the importance of individualized blood pressure management guided by modern data in the context of cerebral autoregulation across varied patient populations.
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Affiliation(s)
- Lingzhong Meng
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Mads Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Nicole Bianca S Libiran
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Semanti Naiken
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kylie S Meacham
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jacob D Schmidt
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Niloy K Lahiri
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jiange Han
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin, China
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - David C Adams
- From the *Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adrian W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
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10
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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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11
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Kasputytė G, Kumpaitienė B, Švagždienė M, Andrejaitienė J, Gailiušas M, Širvinskas E, Gelmanas A, Hamarat Y, Chaleckas E, Putnynaitė V, Bartušis L, Žakelis R, Petkus V, Ragauskas A, Lenkutis T. The Association of Cerebral Autoregulation Dysfunction and Postoperative Memory Impairment in Cardiac Surgery Patients. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1337. [PMID: 39202618 PMCID: PMC11356179 DOI: 10.3390/medicina60081337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 07/24/2024] [Accepted: 08/08/2024] [Indexed: 09/03/2024]
Abstract
Background and Objectives: Cardiac surgery is associated with various durations of cerebral autoregulation (CA) impairment and can significantly impact cognitive function. Cognitive functions such as memory, psychomotor speed, and attention are significantly impacted after cardiac surgery, necessitating prioritization of these areas in cognitive function tests. There is a lack of research connecting cerebral autoregulation impairment to specific cognitive function domains after cardiac surgery. This study aimed to determine if impaired cerebral autoregulation is associated with postoperative memory impairment and to test the hypothesis that the duration of this impairment affects the development of postoperative memory issues. Materials and Methods: A prospective study was conducted in 2021-2023. After approval of the Ethics Committee and with patient's written consent, 83 adult patients undergoing elective on-pump coronary artery bypass graft (CABG) surgery were enrolled. All patients were assessed for cognitive function 1 day before surgery using the Mini-Mental state examination (MMSE-2) test as a screening tool and the Hopkins Verbal Learning Test-Revised (HVLT-R) to assess memory specifically. To diagnose possible memory impairment (IM), all patients underwent a repeat assessment of cognitive function on the 7th-10th postoperative day. Cerebral autoregulation monitoring using transcranial Doppler was performed. Cerebral autoregulation status index (Mx) was recorded using Intensive Care Brain Monitoring System software, 9.1.5.23 (Cambridge, UK). Results: According to our research, the incidence of postoperative memory impairment is 30.1%. Temporary cerebral autoregulation impairment occurs in all patients undergoing elective in-pump CABG surgery. The duration of the single longest CA impairment event in seconds (LCAI) and the LCAI dose were higher in patients with postoperative memory impairment, p = 0.006 and p < 0.007, respectively. Conclusions: Cerebral autoregulation impairment is important in developing memory loss after cardiac surgery. The duration and dose of the LCAI event are predictive of postoperative memory impairment.
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Affiliation(s)
- Greta Kasputytė
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, 50162 Kaunas, Lithuania
| | - Birutė Kumpaitienė
- Department of Disaster Medicine, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Milda Švagždienė
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, 50162 Kaunas, Lithuania
| | - Judita Andrejaitienė
- Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, 50162 Kaunas, Lithuania
| | - Mindaugas Gailiušas
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Edmundas Širvinskas
- Department of Cardiac, Thoracic and Vascular Surgery, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Arūnas Gelmanas
- Department of Anesthesiology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Yasin Hamarat
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Edvinas Chaleckas
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Vilma Putnynaitė
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Laimonas Bartušis
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Rolandas Žakelis
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, 51423 Kaunas, Lithuania (L.B.)
| | - Tadas Lenkutis
- Department of Anesthesiology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
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12
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Miller JB, Hrabec D, Krishnamoorthy V, Kinni H, Brook RD. Evaluation and management of hypertensive emergency. BMJ 2024; 386:e077205. [PMID: 39059997 DOI: 10.1136/bmj-2023-077205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Hypertensive emergencies cause substantial morbidity and mortality, particularly when acute organ injury is present. Careful and effective strategies to reduce blood pressure and diminish the effects of pressure-mediated injury are essential. While the selection of specific antihypertensive medications varies little across different forms of hypertensive emergencies, the intensity of blood pressure reduction to the target pressure differs substantially. Treatment hinges on balancing the positive effects of lowering blood pressure with the potential for negative effects of organ hypoperfusion in patients with altered autoregulatory mechanisms. When patients do not have acute organ injury in addition to severe hypertension, they benefit from a conservative, outpatient approach to blood pressure management. In all cases, long term control of blood pressure is paramount to prevent recurrent hypertensive emergencies and improve overall prognosis. This review discusses the current evidence and guidelines on the evaluation and management of hypertensive emergency.
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Affiliation(s)
- Joseph B Miller
- Department of Emergency Medicine, Division of Critical Care Medicine, Henry Ford Health and Michigan State University Health Sciences, Detroit, MI, USA
| | - Daniel Hrabec
- Department of Emergency Medicine, Division of Critical Care Medicine, Henry Ford Health and Michigan State University Health Sciences, Detroit, MI, USA
| | - Vijay Krishnamoorthy
- Department of Anesthesiology, Division of Critical Care Medicine, Duke University, Durham, NC, USA
| | - Harish Kinni
- Department of Emergency Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert D Brook
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wayne State University, Detroit, MI, USA
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13
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Vu EL, Brown CH, Brady KM, Hogue CW. Monitoring of cerebral blood flow autoregulation: physiologic basis, measurement, and clinical implications. Br J Anaesth 2024; 132:1260-1273. [PMID: 38471987 DOI: 10.1016/j.bja.2024.01.043] [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: 05/02/2023] [Revised: 01/18/2024] [Accepted: 01/28/2024] [Indexed: 03/14/2024] Open
Abstract
Cerebral blood flow (CBF) autoregulation is the physiologic process whereby blood supply to the brain is kept constant over a range of cerebral perfusion pressures ensuring a constant supply of metabolic substrate. Clinical methods for monitoring CBF autoregulation were first developed for neurocritically ill patients and have been extended to surgical patients. These methods are based on measuring the relationship between cerebral perfusion pressure and surrogates of CBF or cerebral blood volume (CBV) at low frequencies (<0.05 Hz) of autoregulation using time or frequency domain analyses. Initially intracranial pressure monitoring or transcranial Doppler assessment of CBF velocity was utilised relative to changes in cerebral perfusion pressure or mean arterial pressure. A more clinically practical approach utilising filtered signals from near infrared spectroscopy monitors as an estimate of CBF has been validated. In contrast to the traditional teaching that 50 mm Hg is the autoregulation threshold, these investigations have found wide interindividual variability of the lower limit of autoregulation ranging from 40 to 90 mm Hg in adults and 20-55 mm Hg in children. Observational data have linked impaired CBF autoregulation metrics to adverse outcomes in patients with traumatic brain injury, ischaemic stroke, subarachnoid haemorrhage, intracerebral haemorrhage, and in surgical patients. CBF autoregulation monitoring has been described in both cardiac and noncardiac surgery. Data from a single-centre randomised study in adults found that targeting arterial pressure during cardiopulmonary bypass to above the lower limit of autoregulation led to a reduction of postoperative delirium and improved memory 1 month after surgery compared with usual care. Together, the growing body of evidence suggests that monitoring CBF autoregulation provides prognostic information on eventual patient outcomes and offers potential for therapeutic intervention. For surgical patients, personalised blood pressure management based on CBF autoregulation data holds promise as a strategy to improve patient neurocognitive outcomes.
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Affiliation(s)
- Eric L Vu
- Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kenneth M Brady
- The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charles W Hogue
- The Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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14
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Abstract
Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Filip De Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, London, UK
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15
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Zulauf FN, Sikora N. CON: There Should be an Individualized Optimal Perfusion Pressure on CPB. J Cardiothorac Vasc Anesth 2024; 38:566-568. [PMID: 37648612 DOI: 10.1053/j.jvca.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Fabio Nicolas Zulauf
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Normunds Sikora
- Children's Clinical University Hospital, Department of Paediatric Cardiology and Cardiac Surgery, Riga Stradins University, Department of Surgery, Riga, Latvia
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16
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Andersen L, Appelblad M, Wiklund U, Sundström N, Svenmarker S. Our initial experience of monitoring the autoregulation of cerebral blood flow during cardiopulmonary bypass. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:209-217. [PMID: 38099638 PMCID: PMC10723576 DOI: 10.1051/ject/2023032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/05/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Cerebral blood flow (CBF) is believed to be relatively constant within an upper and lower blood pressure limit. Different methods are available to monitor CBF autoregulation during surgery. This study aims to critically analyze the application of the cerebral oxygenation index (COx), one of the commonly used techniques, using a reference to data from a series of clinical registrations. METHOD CBF was monitored using near-infrared spectroscopy, while cerebral blood pressure was estimated by recordings obtained from either the radial or femoral artery in 10 patients undergoing cardiopulmonary bypass. The association between CBF and blood pressure was calculated as a moving continuous correlation coefficient. A COx index > 0.4 was regarded as a sign of abnormal cerebral autoregulation (CA). Recordings were examined to discuss reliability measures and clinical feasibility of the measurements, followed by interpretation of individual results, identification of possible pitfalls, and suggestions of alternative methods. RESULTS AND CONCLUSION Monitoring of CA during cardiopulmonary bypass is intriguing and complex. A series of challenges and limitations should be considered before introducing this method into clinical practice.
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Affiliation(s)
- Leon Andersen
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
| | - Micael Appelblad
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University 901 87 Umeå Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University 901 87 Umeå Sweden
| | - Staffan Svenmarker
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University 901 87 Umeå Sweden
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17
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Gavish B, Gottschalk A, Hogue CW, Steppan J. Additional predictors of the lower limit of cerebral autoregulation during cardiac surgery. J Hypertens 2023; 41:1844-1852. [PMID: 37702558 PMCID: PMC10552816 DOI: 10.1097/hjh.0000000000003556] [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: 01/24/2023] [Revised: 05/31/2023] [Accepted: 08/22/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVES The lower limit of autoregulation (LLA) of cerebral blood flow was previously shown to vary directly with the Ambulatory Arterial Stiffness Index (AASI) redefined as 1-regression slope of DBP-versus-SBP readings invasively measured from the radial artery before the bypass. We aimed expanding the predictive capacity of the LLA with AASI by combining it with additional predictors and provide new indications whether mean arterial pressure (MAP) is above/below the LLA. DESIGN AND METHOD In 181 patients undergoing cardiac surgery, mean (SD) age 71 (8) years), we identified from the demographic, preoperative and intraoperative characteristics independent and statistically significant 'single predictors' of the LLA (including AASI). This was achieved using multivariate linear regression with a backward-elimination technique. The single predictors combined with 1-AASI generated new multiplicative and additive composite predictors of the LLA. Indicators for the MAP-to-LLA difference (DIF) were determined using DIF-versus-predictor plots. The odds ratio (OR) for the DIF sign (Outcome = 1 for DIF≤0) and predictor-minus-median sign (Exposure = 1 for Predictor ≤ Median) were calculated using logistic regression. RESULTS BMI, 1-AASI and systolic coefficient of variation were identified single predictors that correlated similarly with the LLA ( r = -0.26 to -0.27, P < 0.001). The multiplicative and additive composite predictors displayed higher correlation with LLA ( r = -0.41 and r = -0.43, respectively, P < 0.001) and improved LLA estimation. The adjusted OR for the composite predictors was nearly twice that of the single predictors. CONCLUSION The novel composite predictors may enhance the LLA estimation and the ability to maintain MAP in the cerebral autoregulatory range during cardiac surgery.
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Affiliation(s)
| | - Allan Gottschalk
- Johns Hopkins University, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
| | - Charles W. Hogue
- Northwestern University Feinberg, Department of Anesthesiology, Chicago, Illinois, USA
| | - Jochen Steppan
- Johns Hopkins University, Department of Anesthesiology and Critical Care Medicine, Baltimore, Maryland
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18
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Relationships between common carotid artery blood flow and anesthesia, pneumoperitoneum, and head-down tilt position: a linear mixed-effect analysis. J Clin Monit Comput 2022; 37:669-677. [PMID: 36463542 DOI: 10.1007/s10877-022-00940-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/25/2022] [Indexed: 12/07/2022]
Abstract
This study investigated the effects of pneumoperitoneum and the head-down tilt position on common carotid artery (CCA) blood flow in surgical patients. METHODS This prospective observational study included 20 patients who underwent gynecological surgery. CCA blood flow was measured using Doppler ultrasound at four-time points: awake in the supine position [T1], 3 min after anesthesia induction in the supine position [T2], 3 min after pneumoperitoneum in the supine position [T3], and 3 min after pneumoperitoneum in the head-down tilt position [T4]. Hemodynamic and respiratory parameters were also recorded at each time point. Linear mixed-effect analyses were performed to compare CCA blood flow across the time points and assess its relationship with hemodynamic parameters. RESULTS Compared with T1, CCA blood flow decreased significantly at T2 (345.4 [288.0-392.9] vs. 293.1 [253.0-342.6], P = 0.048). CCA blood flow were also significantly lower at T3 and T4 compared with T1 (345.4 [288.0-392.9] vs. 283.6 [258.8-307.6] and 287.1 [242.1-321.4], P = 0.005 and 0.016, respectively). CCA blood flow at T3 and T4 did not significantly differ from that at T2. Changes in CCA blood flow were significantly associated with changes in cardiac index and stroke volume index (P = 0.011 and 0.024, respectively). CONCLUSION CCA blood flow was significantly decreased by anesthesia induction. Inducing pneumoperitoneum, with or without the head-down tilt position, did not further decrease CCA blood flow if the cardiac index remained unchanged. The cardiac index and stroke volume index were significantly associated with CCA blood flow. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov (NCT04233177, January 18, 2020).
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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20
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Zipfel J, Wikidal B, Schwaneberg B, Schuhmann MU, Magunia H, Hofbeck M, Schlensak C, Schmid S, Neunhoeffer F. Identifying the optimal blood pressure for cerebral autoregulation in infants after cardiac surgery by monitoring cerebrovascular reactivity-A pilot study. Paediatr Anaesth 2022; 32:1320-1329. [PMID: 36083106 DOI: 10.1111/pan.14555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/13/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Advances in the treatment of pediatric congenital heart disease have increased survival rates. Despite efforts to prevent neurological injury, many patients suffer from impaired neurodevelopmental outcomes. Compromised cerebral autoregulation can increase the risk of brain injury following pediatric cardiac surgery with cardiopulmonary bypass. Monitoring autoregulation and maintaining adequate cerebral blood flow can help prevent neurological injury. AIMS Our objective was to evaluate autoregulation parameters and to define the optimal blood pressure as well as the lower and upper blood pressure limits of autoregulation. METHODS Autoregulation was monitored prospectively in 36 infants after cardiopulmonary bypass surgery for congenital heart defects between January and December 2019. Autoregulation indices were calculated by correlating invasive arterial blood pressure, cortical oxygen saturation, and relative tissue hemoglobin levels with near-infrared spectroscopy parameters. RESULTS The mean patient age was 4.1 ± 2.8 months, and the mean patient weight was 5.2 ± 1.8 kg. Optimal mean arterial pressure could be identified in 88.9% of patients via the hemoglobin volume index and in 91.7% of patients via the cerebral oxygenation index, and a lower limit of autoregulation could be found in 66.7% and 63.9% of patients, respectively. No significant changes in autoregulation indices at the beginning or end of the monitoring period were observed. In 76.5% ± 11.1% and 83.8% ± 9.9% of the 8 and 16 h monitoring times, respectively, the mean blood pressure was inside the range of intact autoregulation (below in 21.5% ± 25.4% and 11.3% ± 16.5% and above in 8.7% ± 10.4% and 6.0% ± 11.0%, respectively). The mean optimal blood pressure was 57.4 ± 8.7 mmHg and 58.2 ± 7.9 mmHg and the mean lower limit of autoregulation was 48.8 ± 8.3 mmHg and 45.5 ± 6.7 mmHg when generated via the hemoglobin volume index and cerebral oxygenation index, respectively. CONCLUSIONS Postoperative noninvasive autoregulation monitoring after cardiac surgery in children can be reliably and safely performed using the hemoglobin volume index and cerebral oxygenation index and provides robust data. This monitoring can be used to identify individual hemodynamic targets to optimize autoregulation, which differs from those recommended in the literature. Further evaluation of this subject is needed.
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Affiliation(s)
- Julian Zipfel
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Berit Wikidal
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Bernadett Schwaneberg
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Martin U Schuhmann
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Harry Magunia
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Michael Hofbeck
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - Simon Schmid
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Felix Neunhoeffer
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
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Kotani Y, Kataoka Y, Izawa J, Fujioka S, Yoshida T, Kumasawa J, Kwong JS. High versus low blood pressure targets for cardiac surgery while on cardiopulmonary bypass. Cochrane Database Syst Rev 2022; 11:CD013494. [PMID: 36448514 PMCID: PMC9709767 DOI: 10.1002/14651858.cd013494.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Cardiac surgery is performed worldwide. Most types of cardiac surgery are performed using cardiopulmonary bypass (CPB). Cardiac surgery performed with CPB is associated with morbidities. CPB needs an extracorporeal circulation that replaces the heart and lungs, and performs circulation, ventilation, and oxygenation of the blood. The lower limit of mean blood pressure to maintain blood flow to vital organs increases in people with chronic hypertension. Because people undergoing cardiac surgery commonly have chronic hypertension, we hypothesised that maintaining a relatively high blood pressure improves desirable outcomes among the people undergoing cardiac surgery with CPB. OBJECTIVES To evaluate the benefits and harms of higher versus lower blood pressure targets during cardiac surgery with CPB. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search of databases was November 2021 and trials registries in January 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing a higher blood pressure target (mean arterial pressure 65 mmHg or greater) with a lower blood pressure target (mean arterial pressure less than 65 mmHg) in adults undergoing cardiac surgery with CPB. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Primary outcomes were 1. acute kidney injury, 2. cognitive deterioration, and 3. all-cause mortality. Secondary outcomes were 4. quality of life, 5. acute ischaemic stroke, 6. haemorrhagic stroke, 7. length of hospital stay, 8. renal replacement therapy, 9. delirium, 10. perioperative transfusion of blood products, and 11. perioperative myocardial infarction. We used GRADE to assess certainty of evidence. MAIN RESULTS We included three RCTs with 737 people compared a higher blood pressure target with a lower blood pressure target during cardiac surgery with CPB. A high blood pressure target may result in little to no difference in acute kidney injury (risk ratio (RR) 1.30, 95% confidence interval (CI) 0.81 to 2.08; I² = 72%; 2 studies, 487 participants; low-certainty evidence), cognitive deterioration (RR 0.82, 95% CI 0.45 to 1.50; I² = 0%; 2 studies, 389 participants; low-certainty evidence), and all-cause mortality (RR 1.33, 95% CI 0.30 to 5.90; I² = 49%; 3 studies, 737 participants; low-certainty evidence). No study reported haemorrhagic stroke. Although a high blood pressure target may increase the length of hospital stay slightly, we found no differences between a higher and a lower blood pressure target for the other secondary outcomes. We also identified one ongoing RCT which is comparing a higher versus a lower blood pressure target among the people who undergo cardiac surgery with CPB. AUTHORS' CONCLUSIONS A high blood pressure target may result in little to no difference in patient outcomes including acute kidney injury and mortality. Given the wide CIs, further studies are needed to confirm the efficacy of a higher blood pressure target among those who undergo cardiac surgery with CPB.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Junichi Izawa
- Division of Critical Care Medicine, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
- Department of Preventive Services, Kyoto University Graduate School of Public Health, Kyoto, Japan
| | - Shoko Fujioka
- Department of Anesthesiology, Jikei University School of Medicine, Tokyo, Japan
| | - Takuo Yoshida
- Intensive Care Unit, Jikei University Kashiwa Hospital, Department of Emergency Medicine, Jikei University School of Medicine, Tokyo, Japan
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine, Sakai City Medical Center, Sakai City, Japan
- Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joey Sw Kwong
- Global Health Nursing, Graduate School of Nursing Science, St Luke's International University, Tokyo, Japan
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22
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Czosnyka M, Santarius T, Donnelly J, van den Dool REC, Sperna Weiland NH. Pro-Con Debate: The Clinical (Ir)relevance of the Lower Limit of Cerebral Autoregulation for Anesthesiologists. Anesth Analg 2022; 135:734-743. [DOI: 10.1213/ane.0000000000006123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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Tas J, Eleveld N, Borg M, Bos KDJ, Langermans AP, van Kuijk SMJ, van der Horst ICC, Elting JWJ, Aries MJH. Cerebral Autoregulation Assessment Using the Near Infrared Spectroscopy ‘NIRS-Only’ High Frequency Methodology in Critically Ill Patients: A Prospective Cross-Sectional Study. Cells 2022; 11:cells11142254. [PMID: 35883697 PMCID: PMC9317651 DOI: 10.3390/cells11142254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 01/10/2023] Open
Abstract
Impairments in cerebral autoregulation (CA) are related to poor clinical outcome. Near infrared spectroscopy (NIRS) is a non-invasive technique applied to estimate CA. Our general purpose was to study the clinical feasibility of a previously published ‘NIRS-only’ CA methodology in a critically ill intensive care unit (ICU) population and determine its relationship with clinical outcome. Bilateral NIRS measurements were performed for 1–2 h. Data segments of ten-minutes were used to calculate transfer function analyses (TFA) CA estimates between high frequency oxyhemoglobin (oxyHb) and deoxyhemoglobin (deoxyHb) signals. The phase shift was corrected for serial time shifts. Criteria were defined to select TFA phase plot segments (segments) with ‘high-pass filter’ characteristics. In 54 patients, 490 out of 729 segments were automatically selected (67%). In 34 primary neurology patients the median (q1–q3) low frequency (LF) phase shift was higher in 19 survivors compared to 15 non-survivors (13° (6.3–35) versus 0.83° (−2.8–13), p = 0.0167). CA estimation using the NIRS-only methodology seems feasible in an ICU population using segment selection for more robust and consistent CA estimations. The ‘NIRS-only’ methodology needs further validation, but has the advantage of being non-invasive without the need for arterial blood pressure monitoring.
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, University Maastricht, 6229 HX Maastricht, The Netherlands; (M.B.); (K.D.J.B.); (A.P.L.); (I.C.C.v.d.H.); (M.J.H.A.)
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, 6229 HX Maastricht, The Netherlands
- Correspondence:
| | - Nick Eleveld
- Department of Neurology and Clinical Neurophysiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (N.E.); (J.W.J.E.)
| | - Melisa Borg
- Department of Intensive Care Medicine, Maastricht University Medical Center+, University Maastricht, 6229 HX Maastricht, The Netherlands; (M.B.); (K.D.J.B.); (A.P.L.); (I.C.C.v.d.H.); (M.J.H.A.)
| | - Kirsten D. J. Bos
- Department of Intensive Care Medicine, Maastricht University Medical Center+, University Maastricht, 6229 HX Maastricht, The Netherlands; (M.B.); (K.D.J.B.); (A.P.L.); (I.C.C.v.d.H.); (M.J.H.A.)
| | - Anne P. Langermans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, University Maastricht, 6229 HX Maastricht, The Netherlands; (M.B.); (K.D.J.B.); (A.P.L.); (I.C.C.v.d.H.); (M.J.H.A.)
| | - Sander M. J. van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, (KEMTA), Maastricht University Medical Center+, 6229 HX Maastricht, The Netherlands;
| | - Iwan C. C. van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, University Maastricht, 6229 HX Maastricht, The Netherlands; (M.B.); (K.D.J.B.); (A.P.L.); (I.C.C.v.d.H.); (M.J.H.A.)
- Cardiovascular Research Institute Maastricht (CARIM), 6229 HX Maastricht, The Netherlands
| | - Jan Willem J. Elting
- Department of Neurology and Clinical Neurophysiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (N.E.); (J.W.J.E.)
| | - Marcel J. H. Aries
- Department of Intensive Care Medicine, Maastricht University Medical Center+, University Maastricht, 6229 HX Maastricht, The Netherlands; (M.B.); (K.D.J.B.); (A.P.L.); (I.C.C.v.d.H.); (M.J.H.A.)
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, 6229 HX Maastricht, The Netherlands
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24
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Comparison of different metrics of cerebral autoregulation in association with major morbidity and mortality after cardiac surgery. Br J Anaesth 2022; 129:22-32. [PMID: 35597624 PMCID: PMC9428920 DOI: 10.1016/j.bja.2022.03.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 01/25/2022] [Accepted: 03/10/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cardiac surgery studies have established the clinical relevance of personalised arterial blood pressure management based on cerebral autoregulation. However, variabilities exist in autoregulation evaluation. We compared the association of several cerebral autoregulation metrics, calculated using different methods, with outcomes after cardiac surgery. METHODS Autoregulation was measured during cardiac surgery in 240 patients. Mean flow index and cerebral oximetry index were calculated as Pearson's correlations between mean arterial pressure (MAP) and transcranial Doppler blood flow velocity or near-infrared spectroscopy signals. The lower limit of autoregulation and optimal mean arterial pressure were identified using mean flow index and cerebral oximetry index. Regression models were used to examine associations of area under curve and duration of mean arterial pressure below thresholds with stroke, acute kidney injury (AKI), and major morbidity and mortality. RESULTS Both mean flow index and cerebral oximetry index identified the cerebral lower limit of autoregulation below which MAP was associated with a higher incidence of AKI and major morbidity and mortality. Based on magnitude and significance of the estimates in adjusted models, the area under curve of MAP < lower limit of autoregulation had the strongest association with AKI and major morbidity and mortality. The odds ratio for area under the curve of MAP < lower limit of autoregulation was 1.05 (95% confidence interval, 1.01-1.09), meaning every 1 mm Hg h increase of area under the curve was associated with an average increase in the odds of AKI by 5%. CONCLUSIONS For cardiac surgery patients, area under curve of MAP < lower limit of autoregulation using mean flow index or cerebral oximetry index had the strongest association with AKI and major morbidity and mortality. Trials are necessary to evaluate this target for MAP management.
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25
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Ookawara S, Ito K, Sasabuchi Y, Miyahara M, Miyashita T, Takemi N, Nagamine C, Nakahara S, Horiuchi Y, Inose N, Shiina M, Murakoshi M, Sanayama H, Hirai K, Morishita Y. Cerebral oxygenation and body mass index association with cognitive function in chronic kidney disease patients without dialysis: a longitudinal study. Sci Rep 2022; 12:10809. [PMID: 35752646 PMCID: PMC9233691 DOI: 10.1038/s41598-022-15129-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/20/2022] [Indexed: 12/30/2022] Open
Abstract
In chronic kidney disease (CKD) patients, the prevalence of cognitive impairment increases with CKD progression; however, longitudinal changes in cognitive performance remain controversial. Few reports have examined the association of cerebral oxygenation with cognitive function in longitudinal studies. In this study, 68 CKD patients were included. Cerebral regional oxygen saturation (rSO2) was monitored. Cognitive function was evaluated using mini-mental state examination (MMSE) score. Clinical assessments were performed at study initiation and 1 year later. MMSE score was higher at second measurement than at study initiation (p = 0.022). Multivariable linear regression analysis showed that changes in MMSE were independently associated with changes in body mass index (BMI, standardized coefficient: 0.260) and cerebral rSO2 (standardized coefficient: 0.345). This was based on clinical factors with p < 0.05 (changes in BMI, cerebral rSO2, and serum albumin level) and the following confounding factors: changes in estimated glomerular filtration rate, hemoglobin level, proteinuria, salt and energy intake, age, presence of diabetes mellitus, history of comorbid cerebrovascular disease, and use of renin–angiotensin system blocker. Further studies with a larger sample size and longer observational period are needed to clarify whether maintaining BMI and cerebral oxygenation improve or prevent the deterioration of cognitive function.
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Affiliation(s)
- Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan. .,Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan.,Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | - Mayako Miyahara
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Tomoka Miyashita
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Nana Takemi
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Chieko Nagamine
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shinobu Nakahara
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yuko Horiuchi
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Nagisa Inose
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Michiko Shiina
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Miho Murakoshi
- Department of Nutrition, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hidenori Sanayama
- Division of Neurology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, Saitama, 330-8503, Japan
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26
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Lankadeva YR, May CN, Bellomo R, Evans RG. Role of perioperative hypotension in postoperative acute kidney injury: a narrative review. Br J Anaesth 2022; 128:931-948. [DOI: 10.1016/j.bja.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/17/2022] [Accepted: 03/01/2022] [Indexed: 12/20/2022] Open
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27
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Lizano-Díez I, Poteet S, Burniol-Garcia A, Cerezales M. The burden of perioperative hypertension/hypotension: A systematic review. PLoS One 2022; 17:e0263737. [PMID: 35139104 PMCID: PMC8827488 DOI: 10.1371/journal.pone.0263737] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/25/2022] [Indexed: 11/30/2022] Open
Abstract
Study objective Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting. Methods We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac). Results A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02–20.826) as well as changes from the patient’s baseline blood pressure (BP) (OR 1.02–1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03–14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018–1.038) and intra- and postsurgical hypotension (OR 1.05–1.22), and hypertension (OR 1.44–2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability. Conclusions The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.
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28
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Vu EL, Brady K, Hogue CW. High-resolution perioperative cerebral blood flow autoregulation measurement: a practical and feasible approach for widespread clinical monitoring. Br J Anaesth 2022; 128:405-408. [PMID: 34996592 DOI: 10.1016/j.bja.2021.12.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022] Open
Abstract
A growing body of evidence demonstrates that excursions of BP below or above the limits of cerebral blood flow autoregulation are associated with complications in patients with neurological injury or for those undergoing cardiac surgery. Moreover, recent evidence suggests that maintaining MAP above the lower limit of cerebral autoregulation during cardiopulmonary bypass reduces the frequency of postoperative delirium and is associated with improved memory 1 month after surgery. Continuous measurement of BP in relation to cerebral autoregulation limits using a virtual patient monitoring platform processing near-infrared spectroscopy digital signals offers the hope of bringing this application to the bedside.
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Affiliation(s)
- Eric L Vu
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kenneth Brady
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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29
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Liu L, Chao Y, Wang X, Chinese Critical Ultrasound Study Group. Shock Resuscitation - the Necessity and Priority of Renal Blood Perfusion Assessment. Aging Dis 2022; 13:1056-1062. [PMID: 35855346 PMCID: PMC9286909 DOI: 10.14336/ad.2022.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/05/2022] [Indexed: 11/05/2022] Open
Abstract
Improving organ perfusion is the aim of shock resuscitation; therefore, improving organ blood perfusion is a direct indicator for shock resuscitation. During shock, different organs have different capacities for blood flow autoregulation. The kidney is an important organ with excellent ability to autoregulate the blood flow and with vulnerability to poor organ perfusion, which places kidney perfusion in a position of necessity and priority relative to that of other organs in shock. Critical-care ultrasonography provides the best evaluation of renal perfusion.
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Affiliation(s)
- Lixia Liu
- Department of Critical Care Medicine, the Fourth Hospital of Hebei Medical University, Shijiazhuang 05001, China.
| | - Yangong Chao
- Department of Critical Care Medicine, the First Affiliated Hospital of Tsinghua University, Beijing 100016, China.
| | - Xiaoting Wang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China.
- Correspondence should be addressed to: Dr. Xiaoting Wang, Chinese Academy of Medical Sciences, Peking Union Medical College, Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing 100730, China.
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30
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Longhitano Y, Iannuzzi F, Bonatti G, Zanza C, Messina A, Godoy D, Dabrowski W, Xiuyun L, Czosnyka M, Pelosi P, Badenes R, Robba C. Cerebral Autoregulation in Non-Brain Injured Patients: A Systematic Review. Front Neurol 2021; 12:732176. [PMID: 34899560 PMCID: PMC8660115 DOI: 10.3389/fneur.2021.732176] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/11/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction: Cerebral autoregulation (CA) plays a fundamental role in the maintenance of adequate cerebral blood flow (CBF). CA monitoring, through direct and indirect techniques, may guide an appropriate therapeutic approach aimed at improving CBF and reducing neurological complications; so far, the role of CA has been investigated mainly in brain-injured patients. The aim of this study is to investigate the role of CA in non-brain injured patients. Methods: A systematic consultation of literature was carried out. Search terms included: “CA and sepsis,” “CA and surgery,” and “CA and non-brain injury.” Results: Our research individualized 294 studies and after screening, 22 studies were analyzed in this study. Studies were divided in three groups: CA in sepsis and septic shock, CA during surgery, and CA in the pediatric population. Studies in sepsis and intraoperative setting highlighted a relationship between the incidence of sepsis-associated delirium and impaired CA. The most investigated setting in the pediatric population is cardiac surgery, but the role and measurement of CA need to be further elucidated. Conclusion: In non-brain injured patients, impaired CA may result in cognitive dysfunction, neurological damage, worst outcome, and increased mortality. Monitoring CA might be a useful tool for the bedside optimization and individualization of the clinical management in this group of patients.
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Affiliation(s)
- Yaroslava Longhitano
- Department of Anesthesiology and Critical Care, AO St. Antonio, Biagio and Cesare Arrigo, Alessandria, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giulia Bonatti
- Anesthesia and Intensive Care, Gaslini Hospital, Genova, Italy
| | - Christian Zanza
- Foundation of "Nuovo Ospedale Alba-Bra" and Department of Emergency Medicine, Anesthesia and Critical Care Division, Michele and Pietro Ferrero Hospital, Verduno, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Daniel Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, 2 Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | | | - Li Xiuyun
- Department of Anesthesiology & Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Department of Surgery, University of Valencia, Valencia, Spain
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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31
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Melvin RL, Abella JR, Patel R, Hagood JM, Berkowitz DE, Mladinov D. Intraoperative utilisation of high-resolution data for cerebral autoregulation: a feasibility study. Br J Anaesth 2021; 128:e217-e219. [PMID: 34872719 DOI: 10.1016/j.bja.2021.10.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/15/2021] [Accepted: 10/18/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ryan L Melvin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Joshua M Hagood
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dan E Berkowitz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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32
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Vu EL, Dunne EC, Bradley A, Zhou A, Carroll MS, Rand CM, Brady KM, Stewart TM, Weese-Mayer DE. Cerebral Autoregulation During Orthostatic Challenge in Congenital Central Hypoventilation Syndrome. Am J Respir Crit Care Med 2021; 205:340-349. [PMID: 34788206 DOI: 10.1164/rccm.202103-0732oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Congenital Central Hypoventilation Syndrome (CCHS) is a rare autonomic disorder with altered regulation of breathing, heart rate (HR), and blood pressure (BP). Aberrant cerebral oxygenation in response to hypercapnia/hypoxia in CCHS raises concern that altered cerebral autoregulation may contribute to CCHS-related, variably impaired neurodevelopment. OBJECTIVES Evaluate cerebral autoregulation in response to orthostatic challenge in CCHS cases vs. controls. METHODS CCHS and age- and sex-matched control subjects were studied with head-up tilt (HUT) testing to induce orthostatic stress. 50 CCHS and 100 control HUT recordings were included. HR, BP, and cerebral oxygen saturation (rSO2) were continuously monitored. Cerebral oximetry index (COx), a real-time measure of cerebral autoregulation based on these measures, was calculated. MAIN RESULTS HUT resulted in greater mean BP decrease from baseline in CCHS vs. controls (11% vs. 6%; p<0.05) and a diminished increase in HR in CCHS vs. controls (11% vs. 18%; p<0.01) in the 5 minutes after tilt-up. Despite a similar COx at baseline, orthostatic provocation within 5 minutes of tilt-up caused a 50% greater increase in COx (p<0.01) and a 29% increase in minutes of impaired autoregulation (p<0.02) in CCHS vs. controls (4.0 vs. 3.1 min). CONCLUSIONS Cerebral autoregulatory mechanisms appear intact in CCHS, but the greater hypotension observed in CCHS consequent to orthostatic provocation is associated with greater values of COx/impaired autoregulation when BP is below lower limits of autoregulation. Effects of repeated orthostatic challenges in everyday living in CCHS necessitate further study to determine their influence on neurodevelopmental disease burden.
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Affiliation(s)
- Eric L Vu
- Northwestern University Feinberg School of Medicine, 12244, Anesthesiology, Chicago, Illinois, United States.,Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Cardiovascular Anesthesia, Department of Anesthesiology, Chicago, Illinois, United States;
| | - Emma C Dunne
- Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Autonomic Medicine, Department of Pediatrics, Chicago, Illinois, United States
| | - Allison Bradley
- Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Autonomic Medicine, Department of Pediatrics, Chicago, Illinois, United States
| | - Amy Zhou
- Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Autonomic Medicine, Department of Pediatrics, Chicago, Illinois, United States
| | - Michael S Carroll
- Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Data Analytics and Reporting, Chicago, Illinois, United States.,Northwestern University Feinberg School of Medicine, 12244, Pediatrics, Chicago, Illinois, United States
| | - Casey M Rand
- Stanley Manne Children's Research Institute, 2430, Chicago, Illinois, United States.,Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Autonomic Medicine, Department of Pediatrics, Chicago, Illinois, United States
| | - Kenneth M Brady
- Northwestern University Feinberg School of Medicine, 12244, Anesthesiology, Chicago, Illinois, United States.,Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Cardiovascular Anesthesia, Department of Anesthesiology, Chicago, Illinois, United States.,Northwestern University Feinberg School of Medicine, 12244, Department of Pediatrics, Chicago, Illinois, United States
| | - Tracey M Stewart
- Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Autonomic Medicine, Department of Pediatrics, Chicago, Illinois, United States
| | - Debra E Weese-Mayer
- Stanley Manne Children's Research Institute, 2430, Chicago, Illinois, United States.,Ann and Robert H Lurie Children's Hospital of Chicago, 2429, Division of Autonomic Medicine, Department of Pediatrics, Chicago, Illinois, United States.,Northwestern University Feinberg School of Medicine, 12244, Department of Pediatrics, Chicago, Illinois, United States
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Cardiac Surgery Associated AKI Prevention Strategies and Medical Treatment for CSA-AKI. J Clin Med 2021; 10:jcm10225285. [PMID: 34830567 PMCID: PMC8618011 DOI: 10.3390/jcm10225285] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury (AKI) is common after cardiac surgery. To date, there are no specific pharmacological therapies. In this review, we summarise the existing evidence for prevention and management of cardiac surgery-associated AKI and outline areas for future research. Preoperatively, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be withheld and nephrotoxins should be avoided to reduce the risk. Intraoperative strategies include goal-directed therapy with individualised blood pressure management and administration of balanced fluids, the use of circuits with biocompatible coatings, application of minimally invasive extracorporeal circulation, and lung protective ventilation. Postoperative management should be in accordance with current KDIGO AKI recommendations.
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Brain and Muscle Oxygen Saturation Combined with Kidney Injury Biomarkers Predict Cardiac Surgery Related Acute Kidney Injury. Diagnostics (Basel) 2021; 11:diagnostics11091591. [PMID: 34573933 PMCID: PMC8466978 DOI: 10.3390/diagnostics11091591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/23/2021] [Accepted: 08/31/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Early identification of patients at risk for cardiac surgery-associated acute kidney injury (CS-AKI) based on novel biomarkers and tissue oxygen saturation might enable intervention to reduce kidney injury. Aims: The study aimed to ascertain whether brain and muscle oxygenation measured by near-infrared spectroscopy (NIRS), in addition to cystatin C and NGAL concentrations, could help with CS-AKI prediction. Methods: This is a single-centre prospective observational study on adult patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). Brain and muscle NIRS were recorded during surgery. Cystatin C was measured on the first postoperative day, while NGAL directly before and 3 h after surgery. Results: CS-AKI was diagnosed in 18 (16%) of 114 patients. NIRS values recorded 20 min after CPB (with cut-off value ≤ 54.5% for muscle and ≤ 62.5% for the brain) were revealed to be the most accurate predictors of CS-AKI. Preoperative NGAL ≥ 91.5 ng/mL, postoperative NGAL ≥ 140.5 ng/mL, and postoperative cystatin C ≥ 1.23 mg/L were identified as independent and significant CS-AKI predictors. Conclusions: Brain and muscle oxygen saturation 20 min after CPB could be considered early parameters possibly related to CS-AKI risk, especially in patients with increased cystatin C and NGAL levels.
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Heterogeneous impact of hypotension on organ perfusion and outcomes: a narrative review. Br J Anaesth 2021; 127:845-861. [PMID: 34392972 DOI: 10.1016/j.bja.2021.06.048] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/08/2021] [Accepted: 06/25/2021] [Indexed: 12/20/2022] Open
Abstract
Arterial blood pressure is the driving force for organ perfusion. Although hypotension is common in acute care, there is a lack of accepted criteria for its definition. Most practitioners regard hypotension as undesirable even in situations that pose no immediate threat to life, but hypotension does not always lead to unfavourable outcomes based on experience and evidence. Thus efforts are needed to better understand the causes, consequences, and treatments of hypotension. This narrative review focuses on the heterogeneous underlying pathophysiological bases of hypotension and their impact on organ perfusion and patient outcomes. We propose the iso-pressure curve with hypotension and hypertension zones as a way to visualize changes in blood pressure. We also propose a haemodynamic pyramid and a pressure-output-resistance triangle to facilitate understanding of why hypotension can have different pathophysiological mechanisms and end-organ effects. We emphasise that hypotension does not always lead to organ hypoperfusion; to the contrary, hypotension may preserve or even increase organ perfusion depending on the relative changes in perfusion pressure and regional vascular resistance and the status of blood pressure autoregulation. Evidence from RCTs does not support the notion that a higher arterial blood pressure target always leads to improved outcomes. Management of blood pressure is not about maintaining a prespecified value, but rather involves ensuring organ perfusion without undue stress on the cardiovascular system.
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Near-infrared Spectroscopy-derived Cerebral Autoregulation Indices Independently Predict Clinical Outcome in Acutely Ill Comatose Patients. J Neurosurg Anesthesiol 2021; 32:234-241. [PMID: 30864999 PMCID: PMC6732251 DOI: 10.1097/ana.0000000000000589] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Outcome prediction in comatose patients with acute brain injury remains challenging. Regional cerebral oxygenation (rSO2) derived from near-infrared spectroscopy (NIRS) is a surrogate for cerebral blood flow and can be used to calculate cerebral autoregulation (CA) continuously at the bedside from the derived cerebral oximetry index (COx). We hypothesized that COx derived thresholds for CA are associated with outcomes in patients with acute coma from neurological injury. METHODS A prospective cohort study was conducted in 88 acutely comatose adults with heterogenous brain injury diagnoses who were continuously monitored with COx for up to 3 consecutive days. Multivariable logistic regression was performed to investigate association between averaged COx and short (in-hospital and 3 mo) and long-term (6 mo) outcomes. RESULTS Six month mortality rate was 62%. Median COx in nonsurvivors at hospital discharge was 0.082 [interquartile range, IQR: 0.045 to 0.160] compared with 0.042 [IQR: -0.005 to 0.110] in survivors (P=0.012). At 6 months, median COx was 0.075 [IQR: 0.27 to 0.158] in nonsurvivors compared with 0.029 [IQR: -0.015 to 0.077] in survivors (P=0.02). In the multivariable logistic regression model adjusted for confounders, average COx ≥0.05 was associated with both in-hospital mortality (adjusted odds ratio [OR]=2.9, 95% confidence interval [CI]=1.15-7.33, P=0.02), mortality at 6 months (adjusted OR=4.4, 95% CI=1.41-13.7, P=0.01), and severe disability (modified Rankin Score ≥4) at 6 months (adjusted OR=4.4, 95% CI=1.07-17.8, P=0.04). Area under the receiver operating characteristic curve for predicting mortality and severe disability at 6 months were 0.783 and 0.825, respectively. CONCLUSIONS Averaged COx ≥0.05 is independently associated with short and long-term mortality and long-term severe disability in acutely comatose adults with neurological injury. We propose that COx ≥0.05 represents an accurate threshold to predict long-term functional outcome in acutely comatose adults.
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Ali J, Cody J, Maldonado Y, Ramakrishna H. Near-Infrared Spectroscopy (NIRS) for Cerebral and Tissue Oximetry: Analysis of Evolving Applications. J Cardiothorac Vasc Anesth 2021; 36:2758-2766. [PMID: 34362641 DOI: 10.1053/j.jvca.2021.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/11/2022]
Abstract
THE USE OF NEAR-INFRARED SPECTROSCOPY (NIRS) has increased significantly worldwide in the past decade. This technology, first described more than 40 years ago, is based on the fact that near-infrared light is able to penetrate biologic tissue and can obtain real-time, noninvasive information on tissue oxygenation and metabolism. In the clinical setting, NIRS has been able to provide clinicians potentially valuable information in patients with impaired microcirculations (systemic and cerebral). Near-infrared spectroscopy has progressed beyond assessment of brain oxygenation to monitor local tissue and muscle oxygenation and perfusion. This review analyzes the published data and provides the clinician a comprehensive account of the perioperative utility of NIRS in cardiac, vascular and thoracic surgery, as well as its increasing role in tissue/muscle oxygenation monitoring.
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Affiliation(s)
- Jafer Ali
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Joseph Cody
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, The Ohio State Wexner Medical Center, Columbus, OH
| | - Yasdet Maldonado
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Mohandas R, Chamarthi G, Bozorgmehri S, Carlson J, Ozrazgat-Baslanti T, Ruchi R, Shukla A, Kazory A, Bihorac A, Canales M, Segal MS. Pro Re Nata Antihypertensive Medications and Adverse Outcomes in Hospitalized Patients: A Propensity-Matched Cohort Study. Hypertension 2021; 78:516-524. [PMID: 34148363 DOI: 10.1161/hypertensionaha.121.17279] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Rajesh Mohandas
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.).,Renal Section, North Florida/South Georgia Veterans Administration, Gainesville (R.M., A.S., M.C., M.S.S.)
| | - Gajapathiraju Chamarthi
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Shahab Bozorgmehri
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Jeremy Carlson
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Tezcan Ozrazgat-Baslanti
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Rupam Ruchi
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Ashutosh Shukla
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.).,Renal Section, North Florida/South Georgia Veterans Administration, Gainesville (R.M., A.S., M.C., M.S.S.)
| | - Amir Kazory
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.)
| | - Muna Canales
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.).,Renal Section, North Florida/South Georgia Veterans Administration, Gainesville (R.M., A.S., M.C., M.S.S.)
| | - Mark S Segal
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville (R.M., G.C., S.B., J.C., T.O.-B., R.R., A.S., A.K., A.B., M.C., M.S.S.).,Renal Section, North Florida/South Georgia Veterans Administration, Gainesville (R.M., A.S., M.C., M.S.S.)
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Intraoperative cerebral oximetry in open heart surgeries reduced postoperative complications: A retrospective study. PLoS One 2021; 16:e0251157. [PMID: 34038405 PMCID: PMC8153416 DOI: 10.1371/journal.pone.0251157] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022] Open
Abstract
Cardiothoracic surgeries are life-saving procedures but often it results in various complications. Intraoperative cerebral oximetry monitoring used to detect regional cerebral oxygen saturation (rScO2) is a non-invasive method that provides prognostic importance in cardiac surgery. The main aim of the present study was to evaluate the association of intraoperative cerebral oxygen monitoring during cardiac surgery on postoperative complications. This was a case-controlled retrospective study conducted on adult patients, who underwent open-heart surgery in National Heart Institute, Malaysia. The case group comprised patients on protocolized cerebral oximetry monitoring. They were treated using a standardized algorithm to maintain rScO2 not lower than 20% of baseline rScO2. The control group comprised patients with matched demographic background, preoperative risk factors, and type of surgical procedures. Propensity score stratification was utilized to contend with selection bias. Retrospective analysis was performed on 240 patients (case group) while comparing it to 407 patients (control group). The non-availability of cerebral oximetry monitoring during surgery was the prominent predictor for all outcome of complications; stroke (OR: 7.66), renal failure needing dialysis (OR: 5.12) and mortality (OR: 20.51). Postoperative complications revealed that there were significant differences for risk of mortality (p<0.001, OR = 20.51), renal failure that required dialysis (p<0.001, OR = 5.12) and stroke (p <0.05, OR = 7.66). Protocolized cerebral oximetry monitoring during cardiothoracic surgeries was found to be associated with lower incidence of stroke, renal failure requiring dialysis and mortality rate.
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Clinical Applications of Near-infrared Spectroscopy Monitoring in Cardiovascular Surgery. Anesthesiology 2021; 134:784-791. [PMID: 33529323 DOI: 10.1097/aln.0000000000003700] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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: 27] [Impact Index Per Article: 6.8] [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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Cerebral autoregulation in the operating room and intensive care unit after cardiac surgery. Br J Anaesth 2021; 126:967-974. [PMID: 33741137 DOI: 10.1016/j.bja.2020.12.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cerebral autoregulation monitoring is a proposed method to monitor perfusion during cardiac surgery. However, limited data exist from the ICU as prior studies have focused on intraoperative measurements. Our objective was to characterise cerebral autoregulation during surgery and early ICU care, and as a secondary analysis to explore associations with delirium. METHODS In patients undergoing cardiac surgery (n=134), cerebral oximetry values and arterial BP were monitored and recorded until the morning after surgery. A moving Pearson's correlation coefficient between mean arterial proessure (MAP) and near-infrared spectroscopy signals generated the cerebral oximetry index (COx). Three metrics were derived: (1) globally impaired autoregulation, (2) MAP time and duration outside limits of autoregulation (MAP dose), and (3) average COx. Delirium was assessed using the 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM) and the Confusion Assessment Method for the ICU (CAM-ICU). Autoregulation metrics were compared using χ2 and rank-sum tests, and associations with delirium were estimated using regression models, adjusted for age, bypass time, and logEuroSCORE. RESULTS The prevalence of globally impaired autoregulation was higher in the operating room vs ICU (40% vs 13%, P<0.001). The MAP dose outside limits of autoregulation was similar in the operating room and ICU (median 16.9 mm Hg×h; inter-quartile range [IQR] 10.1-38.8 vs 16.9 mm Hg×h; IQR 5.4-35.1, P=0.20). In exploratory adjusted analyses, globally impaired autoregulation in the ICU, but not the operating room, was associated with delirium. The MAP dose outside limits of autoregulation in the operating room and ICU was also associated with delirium. CONCLUSIONS Metrics of cerebral autoregulation are altered in the ICU, and may be clinically relevant with respect to delirium. Further studies are needed to investigate these findings and determine possible benefits of autoregulation-based MAP targeting in the ICU.
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Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection? CEN Case Rep 2021. [PMID: 33728600 DOI: 10.1007/s13730-021-00593-y.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.
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Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection? CEN Case Rep 2021; 10:483-489. [PMID: 33728600 DOI: 10.1007/s13730-021-00593-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/09/2021] [Indexed: 12/12/2022] Open
Abstract
In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.
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Acute Kidney Injury following Cardiopulmonary Bypass: A Challenging Picture. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:8873581. [PMID: 33763177 PMCID: PMC7963912 DOI: 10.1155/2021/8873581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/02/2021] [Accepted: 02/18/2021] [Indexed: 01/10/2023]
Abstract
Recent studies have recognized several risk factors for cardiopulmonary bypass- (CPB-) associated acute kidney injury (AKI). However, the lack of early biomarkers for AKI prevents practitioners from intervening in a timely manner. We reviewed the literature with the aim of improving our understanding of the risk factors for CPB-associated AKI, which may increase our ability to prevent or improve this condition. Some novel early biomarkers for AKI have been introduced. In particular, a combinational use of these biomarkers would be helpful to improve clinical outcomes. Furthermore, we discuss several interventions that are aimed at managing CPB-associated AKI, may increase the effect of renal replacement therapy (RRT), and may contribute to preventing CPB-associated AKI. Collectively, the conclusions of this paper are limited by the availability of clinical trial evidence and conflicting definitions of AKI. A guideline is urgently needed for CPB-associated AKI.
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Ookawara S, Ito K, Sasabuchi Y, Ueda Y, Hayasaka H, Kofuji M, Uchida T, Horigome K, Aikawa T, Imada S, Minato S, Miyazawa H, Shimoyama H, Hirai K, Watanabe A, Shimoyama H, Morishita Y. Association between Cerebral Oxygenation, as Evaluated with Near-Infrared Spectroscopy, and Cognitive Function in Patients Undergoing Hemodialysis. Nephron Clin Pract 2021; 145:171-178. [PMID: 33556936 DOI: 10.1159/000513327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The prevalence of cognitive impairment in patients undergoing hemodialysis (HD) is higher than that in healthy controls. To date, studies on the association between cognitive function and cerebral oxygenation in these patients are limited. Therefore, in this study, we aimed to cross-sectionally investigate the association between cognitive assessment scores and clinical factors, including cerebral oxygenation, in patients undergoing HD. METHODS In this observational study, 193 HD patients were included. Cerebral regional oxygen saturation (rSO2) was monitored using an INVOS 5,100c oxygen saturation monitor. Poor cognition was defined as a Mini-Mental State Examination (MMSE) score ≤23. We analyzed the association between MMSE score and clinical factors, including cerebral rSO2. RESULTS MMSE score in HD patients included in this study was 26.8 ± 3.3. There were 164 patients (85%) with MMSE score ≥24 and 29 patients (15%) with an MMSE score ≤23. In the patients with MMSE score ≥24, cerebral rSO2 (53.8% ± 8.3%) was significantly higher than that in patients with MMSE score ≤23 (49.5% ± 9.8%; p = 0.013). Multivariable linear regression analysis was performed using the following confounding factors: age, mean blood pressure, cerebral rSO2, HD duration, ultrafiltration rate, hemoglobin, serum Cr, serum calcium, serum phosphate, total cholesterol, high-density lipoprotein cholesterol levels, serum albumin, presence of diabetes mellitus or chronic glomerulonephritis, history of comorbid cardiovascular or cerebrovascular disease, and use of renin-angiotensin-aldosterone system inhibitors or vitamin D analogs. MMSE score was independently and significantly associated with age (standardized coefficient: -0.244) and cerebral rSO2 (standardized coefficient: 0.180). CONCLUSIONS MMSE score was independently associated with age (negative effect) and cerebral rSO2 (positive effect) in this cross-sectional study. Further prospective studies are needed to clarify whether maintaining cerebral oxygenation prevents the deterioration of cognitive function in patients undergoing HD.
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Affiliation(s)
- Susumu Ookawara
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan,
| | - Kiyonori Ito
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | - Yuichiro Ueda
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideyuki Hayasaka
- Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masaya Kofuji
- Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takayuki Uchida
- Department of Clinical Engineering, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keita Horigome
- Division of Hemodialysis, Yuai Minuma Clinic, Hakuyukai Medical Corporation, Saitama, Japan
| | - Toshiko Aikawa
- Division of Hemodialysis, Yuai Minuma Clinic, Hakuyukai Medical Corporation, Saitama, Japan
| | - Satoru Imada
- Division of Hemodialysis, Yuai Minuma Clinic, Hakuyukai Medical Corporation, Saitama, Japan
| | - Saori Minato
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Haruhisa Miyazawa
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hirofumi Shimoyama
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Keiji Hirai
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Akihisa Watanabe
- Division of Hemodialysis, Yuai Minuma Clinic, Hakuyukai Medical Corporation, Saitama, Japan
| | - Hiromi Shimoyama
- Division of Nephrology, Yuai Clinic, Hakuyukai Medical Corporation, Saitama, Japan
| | - Yoshiyuki Morishita
- Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Shin B, Maler SA, Reddy K, Fleming NW. Use of the Hypotension Prediction Index During Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1769-1775. [PMID: 33446404 DOI: 10.1053/j.jvca.2020.12.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The hypotension prediction index (HPI) is a novel parameter developed by Edwards Lifesciences (Irvine, CA) that is obtained through an algorithm based on arterial pressure waveform characteristics. Past studies have demonstrated its accuracy in predicting hypotensive events in noncardiac surgeries. The authors aimed to evaluate the use of the HPI in cardiac surgeries requiring cardiopulmonary bypass (CPB). DESIGN Prospective cohort feasibility study. SETTING Single university medical center. PARTICIPANTS Sequential adult patients undergoing elective cardiac surgeries requiring CPB between October 1, 2018, and December 31, 2018. INTERVENTIONS HPI monitor was connected to the patient's arterial pressure transducer. Anesthesiologists and surgeons were blinded to the monitor output. MEASUREMENTS AND MAIN RESULTS HPI values and hypotensive events were recorded before and after CPB. The primary outcomes were the area under the curve (AUC) of the receiver operating characteristic curve, sensitivity, and specificity of HPI predicting hypotension. The AUC, sensitivity, and specificity for HPI lead time to hypotension five minutes before the event were 0.90 (95% confidence interval [CI]: 0.853-0.949), 84% (95% CI: 77.7-90.5), and 84% (95% CI: 70.9-96.8), respectively. Ten minutes before the event AUC, sensitivity, and specificity for HPI lead time to hypotension were 0.83 (95% CI: 0.750-0.905), 79% (95% CI: 69.8-88.1), and 74% (95% CI: 58.8-89.6), respectively. Fifteen minutes before the hypotensive event AUC, sensitivity, and specificity for HPI lead time to hypotension were 0.83 (95% CI: 0.746-0.911), 79% (95% CI: 68.4-89.0), and 74% (95% CI: 58.8-89.6), respectively. CONCLUSION HPI predicted hypotensive episodes during cardiac surgeries with a high degree of sensitivity and specificity.
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Affiliation(s)
- Brian Shin
- University of California, Davis, Department of Anesthesiology and Pain Medicine, Sacramento, CA
| | | | - Keerthi Reddy
- Carle Foundation Hospital at University of Illinois Urbana-Champaign, Department of Psychiatry, Champaign, IL
| | - Neal W Fleming
- University of California, Davis, Department of Anesthesiology and Pain Medicine, Sacramento, CA.
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Magruder JT, Weiss SJ, DeAngelis KG, Haddle J, Desai ND, Szeto WY, Acker MA. Correlating oxygen delivery on cardiopulmonary bypass with Society of Thoracic Surgeons outcomes following cardiac surgery. J Thorac Cardiovasc Surg 2020; 164:997-1007. [PMID: 33485654 DOI: 10.1016/j.jtcvs.2020.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/12/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The relationship between low oxygen delivery (DO2) on cardiopulmonary bypass and morbidity and mortality following cardiac surgery remains unexamined. METHODS We reviewed patients undergoing Society of Thoracic Surgeons index procedures from March 2019 to July 2020, coincident with implementation of a new electronic perfusion record that provides for continuous recording of DO2 and flow parameters. Continuous perfusion variables were analyzed using area-over-the-curve (AOC) calculations below predefined thresholds (DO2 <280 mL O2/min/m2, cardiac index <2.2 L/min, hemoglobin < baseline, and mean arterial pressure <65 mm Hg) to quantify depth and duration of potentially harmful exposures. Multivariable logistic regression adjusted by Society of Thoracic Surgeons predicted-risk scores were used to assess for relationship of perfusion variables with the primary composite outcome of any Society of Thoracic Surgeons index procedure, as well as individual Society of Thoracic Surgeons secondary outcomes (eg, mortality, renal failure, prolonged ventilation >24 hours, stroke, sternal wound infection, and reoperation). RESULTS Eight hundred thirty-four patients were included; 42.7% (356) underwent isolated coronary artery bypass grafting (CABG), whereas 57.3% underwent nonisolated CABG (eg, valvular or combined CABG/valvular operations). DO2 <280-AOC trended toward association with the primary outcome across all cases (P = .07), and was significantly associated for all nonisolated CABG cases (P = .02)-more strongly than for cardiac index <2.2-AOC (P = .04), hemoglobin <7-AOC (P = .51), or mean arterial pressure <65-AOC (P = .11). Considering all procedures, DO2 <280-AOC was independently associated prolonged ventilation >24 hours (P = .04), an effect again most pronounced in nonisolated-CABG cases (P = .002), as well as acute kidney injury <72 hours (P = .04). Patients with glomerular filtration rate <65 mL/min and baseline hemoglobin <12.5 g/dL appeared especially vulnerable. CONCLUSIONS Low DO2 on bypass may be associated with morbidity/mortality following cardiac surgery, particularly in patients undergoing nonisolated CABG. These results underscore the importance of goal-directed perfusion strategies.
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Affiliation(s)
- J Trent Magruder
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Katie Gray DeAngelis
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - John Haddle
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Hori D, Nomura Y, Nakano M, Akiyoshi K, Kimura N, Yamaguchi A. Relationship between endothelial function and vascular stiffness on lower limit of cerebral autoregulation in patients undergoing cardiovascular surgery. Artif Organs 2020; 45:382-389. [PMID: 33191501 DOI: 10.1111/aor.13868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/29/2020] [Indexed: 01/02/2023]
Abstract
Hemodynamic management based on cerebral autoregulation range is a possible strategy for preserving major organ perfusion during cardiovascular surgery. The purpose of this study was to evaluate the relation of vascular properties with lower limit of cerebral autoregulation (LLA). LLA was monitored in 66 patients undergoing cardiovascular surgery using near-infrared spectroscopy. To determine the clinical importance of LLA monitoring, association of blood pressure excursions below LLA and acute kidney injury (AKI) was evaluated. Flow-mediated dilation (FMD) and pulse wave velocity (PWV) were measured for the evaluation of endothelial function and aortic stiffness. Variables associated with LLA were evaluated. Excluding patients on hemodialysis, there were 15 patients (25.9%) who developed AKI. Blood pressure excursions below LLA were higher in patients who developed AKI (4.55 mm Hg × hr vs. 1.23 mm Hg × hr, P = .017). In the univariate analysis, prevalence of ischemic heart disease (No IHD: 53 ± 13.0 mm Hg vs. IHD: 60.0 ± 13.6 mm Hg, P = .056) and FMD (r = -0.42, 95% CI -0.61 to -0.19, P < .001) were associated with LLA before cardiopulmonary bypass (CPB). During CPB, calcium channel blocker (No Ca blocker: 42 ± 10.6 mm Hg vs. Ca blocker: 49 ± 14.3 mm Hg, P = .033), diabetes (no DM: 44 ± 13.2 mm Hg vs. DM: 55 ± 10.0 mm Hg, P = .024), FMD (r = -0.32, 95% CI -0.55 to -0.05, P = .021), and PWV (r = 0.28, 95% CI 0.012 to 0.513, P = .041) were associated with LLA. Multivariate analysis showed that FMD was correlated with LLA before CPB (r = -2.19, 95% CI -3.621 to -0.755, P = .003), while PWV was correlated with LLA during CPB (r = 0.01, 95% CI 0.001-0.019, P = .023). Endothelial function and aortic stiffness may be important factors in determining LLA at different phases in cardiovascular surgery.
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Affiliation(s)
- Daijiro Hori
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yohei Nomura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsunori Nakano
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kei Akiyoshi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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D'Ambra MN. Commentary: Personalized Blood Pressure Management During Bypass Reduces Delirium and Memory Loss. Semin Thorac Cardiovasc Surg 2020; 33:441-442. [PMID: 33181308 DOI: 10.1053/j.semtcvs.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/29/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Michael N D'Ambra
- Harvard Medical School (retired), University of Maryland School of Medicine, Baltimore, Maryland.
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