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A pilot study of cerebrovascular reactivity autoregulation after pediatric cardiac arrest
Jennifer K Lee1, Ken M Brady2, Shang-En Chung3
1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA.
Insights
Maintaining optimal blood pressure is crucial for pediatric cardiac arrest survivors. Poor cerebrovascular autoregulation, indicated by blood pressure deviation, may predict worse neurologic outcomes.
Area of Science:
- Pediatric critical care medicine
- Neurocritical care
- Cerebrovascular physiology
Background:
- Improved survival rates post-cardiac arrest necessitate enhanced neurologic resuscitation strategies.
- Cerebrovascular autoregulation plays a vital role in maintaining adequate brain blood flow, especially after critical illness.
Purpose of the Study:
- To investigate the association between cerebrovascular autoregulation and neurologic outcomes in children following cardiac arrest.
- To evaluate the utility of near-infrared spectroscopy (NIRS) for monitoring autoregulation in this population.
Main Methods:
- Near-infrared spectroscopy (NIRS) was used to monitor cerebrovascular autoregulation in 36 children post-cardiac arrest for 72 hours.
- Key metrics included the optimal mean arterial blood pressure (MAPOPT) range and the area under the curve (AUC) of MAP deviation from MAPOPT.
- Neurologic outcomes were assessed via tracheostomy/gastrostomy, neurologic death, and changes in the Pediatric Cerebral Performance Category (PCPC) score.
Main Results:
- In children not requiring extracorporeal membrane oxygenation (ECMO), a higher AUC during the second 24 hours correlated with the need for tracheostomy/gastrostomy (P=0.04).
- Among non-ECMO patients, a greater AUC during the first 48 hours was observed in those who died from neurologic causes compared to survivors or those with cardiovascular death (P=0.04).
- AUC was not significantly associated with changes in PCPC scores when analyzed separately for children with or without ECMO.
Conclusions:
- Deviations in mean arterial blood pressure from the optimal autoregulatory range may predict poor neurologic outcomes after pediatric cardiac arrest.
- This NIRS-based autoregulation monitoring technique shows potential for personalizing blood pressure management goals in pediatric resuscitation.
Aim:
Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest.
Methods:
Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC).
Results:
Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately.
Conclusions:
Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.
