TY - JOUR
T1 - Determining the upper and lower limits of cerebral autoregulation with cerebral oximetry autoregulation curves
T2 - A case series
AU - Rivera-Lara, Lucia
AU - Zorrilla-Vaca, Andres
AU - Healy, Ryan J.
AU - Ziai, Wendy
AU - Hogue, Charles
AU - Geocadin, Romergryko
AU - Radzik, Batya
AU - Palmisano, Caitlin
AU - Mirski, Marek A.
N1 - Funding Information:
Dr. Rivera-Lara is the principal investigator (PI) on an American Academy of Neurology/American Brain Foundation and Covidien/Metronic grant. Dr. Ziai received funding from Headsense, and from the Thomas Jefferson University (speaker for 6th Annual Neurocritical Care Symposium), and she disclosed other support from National Institutes of Neurological Growing evidence supports the utility of using multi-Disorders and Stroke (R01NS046309) for the minimally invasive surgery modal monitoring with near-infrared spectroscopy trial. Dr. Hogue received support for article research from the Nationalplus rt-PA in the treatment of intracerebral hemorrhage trial (MISTIE iii) (NIRS) to measure cerebral autoregulation (CA) and Institutes of Health (NIH). Dr. Hogue’s institution received funding from thereby calculate optimal cerebral perfusion pressure (CPP) Medtronic/Covidien Dublin, Ireland (maker of near-infrared spectroscopy (1). NIRS is a noninvasive and validated technology to mea-Ornim Medical, Inc., Foxborough, MA. He is the PI on an NIH-sponsoredmachines), and he serves as a consultant to Medtronic/Covidien and sure CA (2). NIRS offers two important advantages. First, it clinical study and also received funding from NIH RO1 092259, and provides feasibility to monitor continuous regional cerebral he disclosed off-label product use where autoregulation monitoring is oxygen saturation (rSco2) at the bedside. Second, it has been any potential conflicts of interest.experimental. The remaining authors have disclosed that they do not have proven to be a good surrogate of cerebral blood flow (3). Three For information regarding this article, E-mail: lriver14@jhmi.edu studies have previously shown that patients undergoing cardiac Copyright © 2018 by the Society of Critical Care Medicine and Wolters surgery using cardiopulmonary bypass with a mean arterial Kluwer Health, Inc. All Rights Reserved. blood pressure (MAP) below the lower limit of CA, as deter- DOI: 10.1097/CCM.0000000000003012 mined by NIRS, had worse outcomes (renal failure, delirium,
Publisher Copyright:
Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
PY - 2018/5/1
Y1 - 2018/5/1
N2 - Objective: Critical care guidelines recommend a single target value for mean arterial blood pressure in critically ill patients. However, growing evidence regarding cerebral autoregulation challenges this concept and supports individualizing mean arterial blood pressure targets to prevent brain and kidney hypo- or hyperperfusion. Regional cerebral oxygen saturation derived from near-infrared spectroscopy is an acceptable surrogate for cerebral blood flow and has been validated to measure cerebral autoregulation. This study suggests a novel mechanism to construct autoregulation curves based on near-infrared spectroscopy-measured cerebral oximetry. Design: Case-series study. Setting: Neurocritical care unit in a tertiary medical center. Patients: Patients with acute neurologic injury and Glasgow coma scale score less than or equal to 8. Measurements and Main Results: Autoregulation curves were plotted using the fractional-polynomial model in Stata after multimodal continuous monitoring of regional cerebral oxygen saturation and mean arterial blood pressure. Individualized autoregulation curves of seven patients exhibited varying upper and lower limits of autoregulation and provided useful clinical information on the autoregulation trend (curves moving to the right or left during the acute coma period). The median lower and upper limits of autoregulation were 86.5 mm Hg (interquartile range, 74-93.5) and 93.5 mm Hg (interquartile range, 83-99), respectively. Conclusions: This case-series study showed feasibility of delineating real trends of the cerebral autoregulation plateau and direct visualization of the cerebral autoregulation curve after at least 24 hours of recording without manipulation of mean arterial blood pressure by external stimuli. The integration of multimodal monitoring at the bedside with cerebral oximetry provides a noninvasive method to delineate daily individual cerebral autoregulation curves.
AB - Objective: Critical care guidelines recommend a single target value for mean arterial blood pressure in critically ill patients. However, growing evidence regarding cerebral autoregulation challenges this concept and supports individualizing mean arterial blood pressure targets to prevent brain and kidney hypo- or hyperperfusion. Regional cerebral oxygen saturation derived from near-infrared spectroscopy is an acceptable surrogate for cerebral blood flow and has been validated to measure cerebral autoregulation. This study suggests a novel mechanism to construct autoregulation curves based on near-infrared spectroscopy-measured cerebral oximetry. Design: Case-series study. Setting: Neurocritical care unit in a tertiary medical center. Patients: Patients with acute neurologic injury and Glasgow coma scale score less than or equal to 8. Measurements and Main Results: Autoregulation curves were plotted using the fractional-polynomial model in Stata after multimodal continuous monitoring of regional cerebral oxygen saturation and mean arterial blood pressure. Individualized autoregulation curves of seven patients exhibited varying upper and lower limits of autoregulation and provided useful clinical information on the autoregulation trend (curves moving to the right or left during the acute coma period). The median lower and upper limits of autoregulation were 86.5 mm Hg (interquartile range, 74-93.5) and 93.5 mm Hg (interquartile range, 83-99), respectively. Conclusions: This case-series study showed feasibility of delineating real trends of the cerebral autoregulation plateau and direct visualization of the cerebral autoregulation curve after at least 24 hours of recording without manipulation of mean arterial blood pressure by external stimuli. The integration of multimodal monitoring at the bedside with cerebral oximetry provides a noninvasive method to delineate daily individual cerebral autoregulation curves.
KW - autoregulation curve
KW - cerebral autoregulation
KW - cerebral oximetry
KW - cerebral perfusion
KW - near-infrared spectroscopy
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U2 - 10.1097/CCM.0000000000003012
DO - 10.1097/CCM.0000000000003012
M3 - Article
C2 - 29419556
AN - SCOPUS:85054124156
SN - 0090-3493
VL - 46
SP - e473-e477
JO - Critical care medicine
JF - Critical care medicine
IS - 5
ER -