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A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury
Published on: March 26, 2019
Brain monitoring and protection during pediatric cardiac surgery
Glyn D Williams1, Chandra Ramamoorthy
1Department of Anesthesia, Stanford University Medical School, California 94305, USA. jumbo@stanford.edu
Insights
Long-term neurodevelopmental outcomes are a growing concern after congenital heart disease surgery. New monitoring and neuroprotective strategies aim to improve brain health in children undergoing these procedures.
Area of Science:
- Pediatric Cardiology
- Neuroscience
- Critical Care Medicine
Background:
- Improved survival in congenital heart disease (CHD) necessitates focus on long-term neurodevelopmental outcomes.
- Brain injury is common in neonates with CHD before surgery, linked to cardiac defects and altered cerebral blood flow.
- Cardiopulmonary bypass and deep hypothermic circulatory arrest are associated with adverse neurologic outcomes.
Purpose of the Study:
- To review current strategies for optimizing neurologic outcomes in children undergoing cardiac surgery for CHD.
- To examine the role of perioperative neurologic monitoring in identifying and predicting adverse events.
- To discuss evolving neuroprotective measures and perfusion techniques.
Main Methods:
- Review of neuroprotective strategies including temperature regulation, acid-base management, hemodilution, glucose control, and anti-inflammatory therapies.
- Discussion of perioperative neurologic monitoring modalities: processed electroencephalography (EEG), near-infrared spectroscopy (NIRS), and transcranial Doppler (TCD) ultrasound.
- Evaluation of alternative perfusion techniques like regional antegrade cerebral perfusion.
Main Results:
- Perioperative monitoring technologies are becoming more accessible and useful for identifying neurologic events and predicting outcomes.
- Alternative perfusion strategies and neuroprotective measures show promise in mitigating brain injury.
- Evidence for the impact of specific interventions on neurologic outcomes is examined, highlighting areas for further research.
Conclusions:
- Optimizing neurologic outcomes in children with CHD requires a multi-faceted approach involving advanced monitoring and neuroprotective strategies.
- Continued research is needed to fully understand and address the complexities of neurologic function in this population.
- Technological advancements are enhancing the ability to monitor and potentially improve brain health during and after cardiac surgery.
Abstract:
With advances in medical care, survival after cardiac surgery for congenital heart disease has dramatically improved, and attention is increasingly focused on long-term functional morbidities, especially neurodevelopmental outcomes, with their profound consequences to patients and society. There are multiple reasons for concern about brain injury. Some cardiac defects are associated with brain anomalies and altered cerebral blood flow regulation. Brain imaging studies have demonstrated that injury to gray and white matter is quite frequent before heart surgery in neonates. Cardiopulmonary bypass and deep hypothermic circulatory arrest are associated with short- and longer-term adverse neurologic outcome. Additional brain injury can occur during the patient's recovery from surgery. Strategies to optimize neurologic outcome continue to evolve. With new technological developments, perioperative neurologic monitoring of small children has become easier, and data suggest these modalities usefully identify adverse neurologic events and might predict outcome. Monitoring methods to be discussed include processed electroencephalography, near infrared spectroscopy, and transcranial Doppler ultrasound. Alternative perfusion techniques to deep hypothermic circulatory arrest have been developed, such as regional antegrade cerebral perfusion during cardiopulmonary bypass. Other neuroprotective strategies employed during open-heart surgery include temperature regulation, acid-base management, degree of hemodilution, blood glucose control and anti-inflammatory therapies. Evidence of the impact of these measures on neurologic outcome is examined, and deficiencies in our current understanding of neurologic function in children with congenital heart disease are identified.
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