Mitsunori Nakano1, Yohei Nomura1, Glenn Whitman2, Marc Sussman2, Stefano Schena2, Ahmet Kilic2, Chun W Choi2, Kei Akiyoshi3, Karin J Neufeld4, Jennifer Lawton2, Elizabeth Colantuoni5, Atsushi Yamaguchi1, Matthew Wen3, Peter Smielewski6, Ken Brady7, Brian Bush3, Charles W Hogue7, Charles H Brown8. 1. Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan. 2. Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 3. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 4. Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 5. Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 6. Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK. 7. Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. 8. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: cbrownv@jhmi.edu.
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.
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.
Authors: E W Ely; R Margolin; J Francis; L May; B Truman; R Dittus; T Speroff; S Gautam; G R Bernard; S K Inouye Journal: Crit Care Med Date: 2001-07 Impact factor: 7.598
Authors: Nicolai Goettel; Christoph S Burkhart; Ariane Rossi; Brenno C T Cabella; Manfred Berres; Andreas U Monsch; Marek Czosnyka; Luzius A Steiner Journal: Anesth Analg Date: 2017-03 Impact factor: 5.108
Authors: Tamara G Fong; Sarinnapha M Vasunilashorn; Edward R Marcantonio; Sharon K Inouye; Long Ngo; Towia A Libermann; Simon T Dillon; Eva M Schmitt; Alvaro Pascual-Leone; Steven E Arnold; Richard N Jones Journal: Ann Neurol Date: 2020-09-15 Impact factor: 10.422
Authors: Edward R Marcantonio; Long H Ngo; Margaret O'Connor; Richard N Jones; Paul K Crane; Eran D Metzger; Sharon K Inouye Journal: Ann Intern Med Date: 2014-10-21 Impact factor: 25.391
Authors: Jilles B Bijker; Wilton A van Klei; Teus H Kappen; Leo van Wolfswinkel; Karel G M Moons; Cor J Kalkman Journal: Anesthesiology Date: 2007-08 Impact factor: 7.892
Authors: Charles H Brown; Julia Probert; Ryan Healy; Michelle Parish; Yohei Nomura; Atsushi Yamaguchi; Jing Tian; Kenton Zehr; Kaushik Mandal; Vidyulata Kamath; Karin J Neufeld; Charles W Hogue Journal: Anesthesiology Date: 2018-09 Impact factor: 7.892
Authors: Masahiro Ono; George J Arnaoutakis; Derek M Fine; Kenneth Brady; R Blaine Easley; Yueying Zheng; Charles Brown; Nevin M Katz; Morgan E Grams; Charles W Hogue Journal: Crit Care Med Date: 2013-02 Impact factor: 7.598
Authors: Juliana R Caldas; Ronney B Panerai; Edson Bor-Seng-Shu; Graziela S R Ferreira; Ligia Camara; R H Passos; Marcelo de-Lima-Oliveira; Filomena R B G Galas; Juliano P Almeida; Ricardo C Nogueira; Natalia Mian; Fabio A Gaiotto; Thompson G Robinson; Ludhmila A Hajjar Journal: Clin Neurophysiol Date: 2018-11-22 Impact factor: 3.708
Authors: Xiuyun Liu; Joseph Donnelly; Ken M Brady; Kei Akiyoshi; Brian Bush; Raymond C Koehler; Jennifer K Lee; Charles W Hogue; Marek Czosnyka; Peter Smielewski; Charles H Brown Journal: Br J Anaesth Date: 2022-05-18 Impact factor: 11.719
Authors: Xiuyun Liu; Mitsunori Nakano; Atsushi Yamaguchi; Brian Bush; Kei Akiyoshi; Jennifer K Lee; Raymond C Koehler; Charles W Hogue; Charles H Brown Journal: J Clin Anesth Date: 2021-06-17 Impact factor: 9.452
Authors: Johanna Laurikkala; Anders Aneman; Alexander Peng; Matti Reinikainen; Paul Pham; Pekka Jakkula; Johanna Hästbacka; Erika Wilkman; Pekka Loisa; Jussi Toppila; Thomas Birkelund; Kaj Blennow; Henrik Zetterberg; Markus B Skrifvars Journal: Crit Care Date: 2021-09-28 Impact factor: 9.097