Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2017

Open Access 01-12-2017 | Viewpoint

Individualized perfusion targets in hypoxic ischemic brain injury after cardiac arrest

Authors: Mypinder S. Sekhon, Donald E. Griesdale

Published in: Critical Care | Issue 1/2017

Login to get access

Abstract

Secondary injury is a major determinant of outcome in hypoxic ischemic brain injury (HIBI) after cardiac arrest and may be mitigated by optimizing cerebral oxygen delivery (CDO2). CDO2 is determined by cerebral blood flow (CBF), which is dependent upon mean arterial pressure (MAP). In health, CBF remains constant over the MAP range through cerebral autoregulation. In HIBI, the zone of intact cerebral autoregulation is narrowed and varies for each patient. Maintaining MAP within the intact autoregulation zone may mitigate ischemia, hyperemia and secondary injury. The optimal MAP in individual patients can be determined using real time autoregulation monitoring techniques.
Literature
1.
Sekhon MS, Ainslie PN, Griesdale DE. Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: a “two-hit” model. Crit Care. 2017;21:90.CrossRefPubMedPubMedCentral
2.
Nielsen N, Wetterslev J, Cronberg T, Erlinge D, Gasche Y, Hassager C, et al. Targeted temperature management at 33 °C versus 36 °C after cardiac arrest. N Engl J Med. 2013;369:2197–206.CrossRefPubMed
3.
Nolan JP, Neumar RW, Adrie C, Aibiki M, Berg RA, Böttiger BW, et al. Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication. A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Coun. Resuscitation. 2008;79:350–79.CrossRefPubMed
4.
Peberdy MA, Callaway CW, Neumar RW, Geocadin RG, Zimmerman JL, Donnino M, et al. Part 9: Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S768–86.CrossRefPubMed
5.
Bhate TD, McDonald B, Sekhon MS, Griesdale DEG. Association between blood pressure and outcomes in patients after cardiac arrest: a systematic review. Resuscitation. 2015;97:1–6.CrossRefPubMed
6.
Brady K, Joshi B, Zweifel C, Smielewski P, Czosnyka M, Easley RB, et al. Real-time continuous monitoring of cerebral blood flow autoregulation using near-infrared spectroscopy in patients undergoing cardiopulmonary bypass. Stroke. 2010;41:1951–6.CrossRefPubMedPubMedCentral
7.
Filosa JA, Iddings JA. Astrocyte regulation of cerebral vascular tone. AJP Hear Circ Physiol. 2013;305:H609–19.CrossRef
8.
Nishizawa H, Kudoh I. Cerebral autoregulation is impaired in patients resuscitated after cardiac arrest. Acta Anaesthesiol Scand. 1996;40:1149–53.CrossRefPubMed
9.
Sundgreen C, Larsen FS, Herzog TM, Knudsen GM, Boesgaard S, Aldershvile J. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke. 2001;32:128–32.CrossRefPubMed
10.
Ameloot K, Genbrugge C, Meex I, Jans F, Boer W, Vander Laenen M, et al. An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: time to drop “one-size-fits-all” hemodynamic targets? Resuscitation. 2015;90:121–6.CrossRefPubMed
11.
Busl KM, Greer DM. Hypoxic-ischemic brain injury: pathophysiology, neuropathology and mechanisms. NeuroRehabilitation. 2010;26:5–13.PubMed
12.
Böttiger BW, Krumnikl JJ, Gass P, Schmitz B, Motsch J, Martin E. The cerebral “no-reflow” phenomenon after cardiac arrest in rats--influence of low-flow reperfusion. Resuscitation. 1997;34:79–87.CrossRefPubMed
13.
Lee JK, Brady KM, Mytar JO, Kibler KK, Carter EL, Hirsch KG, et al. Cerebral blood flow and cerebrovascular autoregulation in a swine model of pediatric cardiac arrest and hypothermia. Crit Care Med. 2011;39:2337–45.CrossRefPubMedPubMedCentral
14.
Trzeciak S, Jones AE, Kilgannon JH, Milcarek B, Hunter K, Shapiro NI, et al. Significance of arterial hypotension after resuscitation from cardiac arrest. Crit Care Med. 2009;37:2895–903.CrossRefPubMed
15.
Laurikkala J, Wilkman E, Pettilä V, Kurola J, Reinikainen M, Hoppu S, et al. Mean arterial pressure and vasopressor load after out-of-hospital cardiac arrest: associations with one-year neurologic outcome. Resuscitation. 2016;105:116–22.CrossRefPubMed
16.
Ameloot K, Meex I, Genbrugge C, Jans F, Boer W, Verhaert D, et al. Hemodynamic targets during therapeutic hypothermia after cardiac arrest: a prospective observational study. Resuscitation. 2015;91:56–62.CrossRefPubMed
17.
Young MN, Hollenbeck RD, Pollock JS, Giuseffi JL, Wang L, Harrell FE, et al. Higher achieved mean arterial pressure during therapeutic hypothermia is not associated with neurologically intact survival following cardiac arrest. Resuscitation. 2015;88:158–64.CrossRefPubMed
18.
Kilgannon JH, Roberts BW, Jones AE, Mittal N, Cohen E, Mitchell J, et al. Arterial blood pressure and neurologic outcome after resuscitation from cardiac arrest. Crit Care Med. 2014;42:2083–91.CrossRefPubMed
19.
Bray JE, Bernard S, Cantwell K, Stephenson M, Smith K, VACAR Steering Committee. The association between systolic blood pressure on arrival at hospital and outcome in adults surviving from out-of-hospital cardiac arrests of presumed cardiac aetiology. Resuscitation. 2014;85:509–15.CrossRefPubMed
20.
Kaji AH, Hanif AM, Thomas JL, Niemann JT. Out-of-hospital cardiac arrest: Early in-hospital hypotension versus out-of-hospital factors in predicting in-hospital mortality among those surviving to hospital admission. Resuscitation. 2011;82:1314–7.CrossRefPubMed
21.
Russo JJ, James TE, Hibbert B, Yousef A, Osborne C, Wells GA, et al. Impact of mean arterial pressure on clinical outcomes in comatose survivors of out-of-hospital cardiac arrest: insights from the University of Ottawa Heart Institute Regional Cardiac Arrest Registry (CAPITAL-CARe). Resuscitation. 2017;113:27–32.CrossRefPubMed
22.
Soar J, Callaway CW, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, et al. Part 4: Advanced life support. Resuscitation. 2015;95:e71–120.CrossRefPubMed
23.
Gaieski DF, Beylin ME, Abella BS, Grossestreuer AV, Perman SM. What is the optimal post-arrest hemodynamic strategy? Towards personalized resuscitation strategies. Intensive Care Med. 2014;40:466.CrossRefPubMed
24.
Zweifel C, Castellani G, Czosnyka M, Carrera E, Brady KM, Kirkpatrick PJ, et al. Continuous assessment of cerebral autoregulation with near-infrared spectroscopy in adults after subarachnoid hemorrhage. Stroke. 2010;41:1963–8.CrossRefPubMed
25.
Brady KM, Mytar JO, Kibler KK, Hogue CW, Lee JK, Czosnyka M, et al. Noninvasive autoregulation monitoring with and without intracranial pressure in the naive piglet brain. Anesth Analg. 2010;111:191–5.PubMedPubMedCentral
26.
Brady KM, Lee JK, Kibler KK, Smielewski P, Czosnyka M, Easley RB, et al. Continuous time-domain analysis of cerebrovascular autoregulation using near-infrared spectroscopy. Stroke. 2007;38:2818–25.CrossRefPubMedPubMedCentral
27.
Lee JK, Kibler KK, Benni PB, Easley RB, Czosnyka M, Smielewski P, et al. Cerebrovascular reactivity measured by near-infrared spectroscopy. Stroke. 2009;40:1820–6.CrossRefPubMed
28.
Sekhon MS, Smielewski P, Bhate TD, Brasher PM, Foster D, Menon DK, et al. Using the relationship between brain tissue regional saturation of oxygen and mean arterial pressure to determine the optimal mean arterial pressure in patients following cardiac arrest: a pilot proof-of-concept study. Resuscitation. 2016;106:120–5.CrossRefPubMed
29.
Brady KM, Lee JK, Kibler KK, Easley RB, Koehler RC, Shaffner DH. Continuous measurement of autoregulation by spontaneous fluctuations in cerebral perfusion pressure: comparison of 3 methods. Stroke. 2008;39:2531–7.CrossRefPubMedPubMedCentral
30.
Howlett JA, Northington FJ, Gilmore MM, Tekes A, Huisman TAGM, Parkinson C, et al. Cerebrovascular autoregulation and neurologic injury in neonatal hypoxic-ischemic encephalopathy. Pediatr Res. 2013;74:525–35.CrossRefPubMedPubMedCentral
31.
Lee JK, Poretti A, Perin J, Huisman TAGM, Parkinson C, Chavez-Valdez R, et al. Optimizing cerebral autoregulation may decrease neonatal regional hypoxic-ischemic brain injury. Dev Neurosci. 2017;39:248–56.CrossRefPubMed
32.
Lee JK, Brady KM, Chung S-E, Jennings JM, Whitaker EE, Aganga D, et al. A pilot study of cerebrovascular reactivity autoregulation after pediatric cardiac arrest. Resuscitation. 2014;85:1387–93.CrossRefPubMedPubMedCentral
33.
Burton VJ, Gerner G, Cristofalo E, Chung S, Jennings JM, Parkinson C, et al. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol. 2015;15:209.CrossRefPubMedPubMedCentral
34.
Pham P, Bindra J, Chuan A, Jaeger M, Aneman A. Are changes in cerebrovascular autoregulation following cardiac arrest associated with neurological outcome? Results of a pilot study. Resuscitation. 2015;96:192–8.CrossRefPubMed
35.
Lavinio A, Timofeev I, Nortje J, Outtrim J, Smielewski P, Gupta A, et al. Cerebrovascular reactivity during hypothermia and rewarming. Br J Anaesth. 2007;99:237–44.CrossRefPubMed
36.
Steiner L a, Czosnyka M, Piechnik SK, Smielewski P, Chatfield D, Menon DK, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med. 2002;30:733–8.CrossRefPubMed
37.
Jaeger M, Schuhmann MU, Soehle M, Meixensberger J. Continuous assessment of cerebrovascular autoregulation after traumatic brain injury using brain tissue oxygen pressure reactivity. Crit Care Med. 2006;34:1783–8.CrossRefPubMed
38.
Aries MJ, Czosnyka M, Budohoski KP, Steiner LA, Lavinio A, Kolias AG, et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med. 2012;40:2456–63.CrossRefPubMed
39.
Ghosh A, Elwell C, Smith M. Review article: cerebral near-infrared spectroscopy in adults: a work in progress. Anesth Analg. 2012;115:1373–83.CrossRefPubMed
Metadata
Title
Individualized perfusion targets in hypoxic ischemic brain injury after cardiac arrest
Authors
Mypinder S. Sekhon
Donald E. Griesdale
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2017
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-017-1832-9

Other articles of this Issue 1/2017

Critical Care 1/2017 Go to the issue

Letter

Patients want to be heard–loud and clear!

Research

Trials directly comparing alternative spontaneous breathing trial techniques: a systematic review and meta-analysis

Research

Untangling glycaemia and mortality in critical care

Research

Prognostic value of platelet-to-lymphocyte ratios among critically ill patients with acute kidney injury

Research

Predictors of hospital and one-year mortality in intensive care patients with refractory status epilepticus: a population-based study

Research

The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis