Identifying the optimal blood pressure for cerebral autoregulation in infants after cardiac surgery by monitoring cerebrovascular reactivity-A pilot study.
(non)invasive monitoring
cardiac surgery
congenital heart disease
critical care
Journal
Paediatric anaesthesia
ISSN: 1460-9592
Titre abrégé: Paediatr Anaesth
Pays: France
ID NLM: 9206575
Informations de publication
Date de publication:
12 2022
12 2022
Historique:
revised:
13
08
2022
received:
24
05
2021
accepted:
05
09
2022
pubmed:
10
9
2022
medline:
15
11
2022
entrez:
9
9
2022
Statut:
ppublish
Résumé
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. 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. 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. 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. 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.
Sections du résumé
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.
Substances chimiques
Hemoglobins
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1320-1329Informations de copyright
© 2022 The Authors. Pediatric Anesthesia published by John Wiley & Sons Ltd.
Références
Rhee CJ, da Costa CS, Austin T, et al. Neonatal cerebrovascular autoregulation. Pediatr Res. 2018;84(5):602-610.
Fantini S, Sassaroli A, Tgavalekos KT, Kornbluth J. Cerebral blood flow and autoregulation: current measurement techniques and prospects for noninvasive optical methods. Neurophotonics. 2016;3(3):31411.
Andropoulos DB, Easley RB, Gottlieb EA, Brady K. Neurologic injury in neonates undergoing cardiac surgery. Clin Perinatol. 2019;46(4):657-671.
Padawer-Curry JA, Volk LE, Mavroudis CD, et al. Effects of circulatory arrest and cardiopulmonary bypass on autoregulation in neonatal swine. Pediatr Res. 2022;91(6):1374-1382.
Brown CH, Neufeld KJ, Tian J, et al. Effect of targeting mean arterial pressure during cardiopulmonary bypass by monitoring autoregulation on postsurgical delirium among older patients: a nested randomized clinical trial. JAMA Surg. 2019;154(9):819-826.
Chan MJ, Chung T, Glassford NJ, Bellomo R. Near-infrared spectroscopy in adult cardiac surgery patients: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2017;31(4):1155-1165.
Zaleski KL, Kussman BD. Near-infrared spectroscopy in pediatric congenital heart disease. J Cardiothorac Vasc Anesth. 2020;34(2):489-500.
Mille T, Tachimiri ME, Klersy C, et al. Near infrared spectroscopy monitoring during carotid endarterectomy: which threshold value is critical? Eur J Vasc Endovasc Surg. 2004;27(6):646-650.
Pedrini L, Magnoni F, Sensi L, et al. Is near-infrared spectroscopy a reliable method to evaluate clamping ischemia during carotid surgery? Stroke Res Treat. 2012;2012:156975.
Moerman A, De Hert S. Recent advances in cerebral oximetry. Assessment of autoregulation with near-infrared spectroscopy: myth or reality? F1000Res. 2017;6:1615.
Brady KM, Mytar JO, Lee JK, et al. Monitoring cerebral blood flow pressure autoregulation in pediatric patients during cardiac surgery. Stroke. 2010;41(9):1957-1962.
Brady KM, Lee JK, Kibler KK, et al. Continuous measurement of autoregulation by spontaneous fluctuations in cerebral perfusion pressure: comparison of 3 methods. Stroke. 2008;39(9):2531-2537.
Lee JK, Williams M, Jennings JM, et al. Cerebrovascular autoregulation in pediatric moyamoya disease. Paediatr Anaesth. 2013;23(6):547-556.
Liu X, Akiyoshi K, Nakano M, et al. Determining thresholds for three indices of autoregulation to identify the lower limit of autoregulation during cardiac surgery. Crit Care Med. 2021;49(4):650-660.
Ono M, Arnaoutakis GJ, Fine DM, et al. Blood pressure excursions below the autoregulation threshold during cardiac surgery are associated with acute kidney injury. Crit Care Med. 2013;41(2):464-471.
Cabrera AG, Kibler KK, Blaine Easley R, et al. Elevated arterial blood pressure after superior cavo-pulmonary anastomosis is associated with elevated pulmonary artery pressure and cerebrovascular dysautoregulation. Pediatr Res. 2018;84(3):356-361.
Rhondali O, Juhel S, Mathews S, et al. Impact of sevoflurane anesthesia on brain oxygenation in children younger than 2 years. Paediatr Anaesth. 2014;24(7):734-740.
Ulate KP, Yanay O, Jeffries H, Baden H, Di Gennaro JL, Zimmerman J. An elevated low cardiac output syndrome score is associated with morbidity in infants after congenital heart surgery. Pediatr Crit Care Med. 2017;18(1):26-33.
Joram N, Beqiri E, Pezzato S, et al. Continuous monitoring of autoregulation in children supported by extracorporeal membrane oxygenation: a pilot study. Neurocrit Care. 2021;34(3):935-945.
Li J, Zhang G, McCrindle BW, et al. Profiles of hemodynamics and oxygen transport derived by using continuous measured oxygen consumption after the Norwood procedure. J Thorac Cardiovasc Surg. 2007;133(2):441-448.
Votava-Smith JK, Statile CJ, Taylor MD, et al. Impaired autoregulation in preoperative newborn infants with congenital heart disease. J Thorac Cardiovasc Surg. 2017;154(3):1038-1044.
Easley RB, Marino BS, Jennings J, et al. Impaired autoregulation and elevation in plasma glial fibrillary acidic protein level during cardiopulmonary bypass surgery for CHD. Cardiol Young. 2018;28(1):55-65.
Lee JK. Cerebral perfusion pressure: how low can we go? Paediatr Anaesth. 2014;24(7):647-648.
Vavilala MS, Lee LA, Lam AM. The lower limit of autoregulation in children during sevoflurane anesthesia. J Neurosurg Anesthesiol. 2003;15(4):307-312.
Liu X, Donnelly J, Brady KM, et al. Comparison of different metrics of autoregulation in association with major morbidity and mortality after cardiac surgery. Br J Anaesth. 2022;129(1):22-32.